Provider Demographics
NPI:1477894269
Name:TERRELL, MARY KATHRYN (BA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:TERRELL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:448 WYLIE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5405
Mailing Address - Country:US
Mailing Address - Phone:618-512-1502
Mailing Address - Fax:
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
IL178.016917101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker