Provider Demographics
NPI:1619009552
Name:MORGAN, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:MORGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:MORGAN
Other - Last Name:VON BUSKIRK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1200 ESPLANADE APT 322
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4968
Mailing Address - Country:US
Mailing Address - Phone:310-902-5942
Mailing Address - Fax:
Practice Address - Street 1:3320 N MILWAUKEE ST STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0775
Practice Address - Country:US
Practice Address - Phone:310-902-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39280106H00000X
CA39280106H00000X
IDLMFT-4955106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC011054Medicaid