Provider Demographics
NPI:1497313472
Name:TERRELL, CASEY (RD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 BEECH DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2400
Mailing Address - Country:US
Mailing Address - Phone:803-646-8343
Mailing Address - Fax:
Practice Address - Street 1:3155 BEECH DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2400
Practice Address - Country:US
Practice Address - Phone:803-646-8343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered