Provider Demographics
NPI:1568636421
Name:TERRELL, TEAL (LMT)
Entity Type:Individual
Prefix:
First Name:TEAL
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W DOVE VALLEY RD APT 363
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5222
Mailing Address - Country:US
Mailing Address - Phone:518-378-7005
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR BLDG 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-266-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT05837225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist