Provider Demographics
NPI:1508574591
Name:SHIMIZU, TERRI THAO LE
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:THAO LE
Last Name:SHIMIZU
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 1:440 W WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PENNDEL
Mailing Address - State:PA
Mailing Address - Zip Code:19047-5130
Mailing Address - Country:US
Mailing Address - Phone:267-577-6281
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:215-983-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0200841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical