Provider Demographics
NPI:1437682549
Name:TERRY, KATHERINE MICHELLE (10100000X)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELLE
Last Name:TERRY
Suffix:
Gender:F
Credentials:10100000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 ALMIRA DRIVE NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311
Mailing Address - Country:US
Mailing Address - Phone:360-373-5031
Mailing Address - Fax:360-415-5894
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8330
Practice Address - Country:US
Practice Address - Phone:360-373-5031
Practice Address - Fax:360-415-5894
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60619572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101Y00000XMedicaid