Provider Demographics
NPI:1467851568
Name:CANTERBURY, TERRIE
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:
Last Name:CANTERBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 FENDLEY RD
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:AR
Mailing Address - Zip Code:71929-6029
Mailing Address - Country:US
Mailing Address - Phone:501-802-7416
Mailing Address - Fax:
Practice Address - Street 1:1655 FENDLEY RD
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:AR
Practice Address - Zip Code:71929-6029
Practice Address - Country:US
Practice Address - Phone:501-802-7416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YM0800X
AR1134243579104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1134243579Medicaid
AR$$$$$$$$$Medicaid