Provider Demographics
NPI:1619459237
Name:TERRY, LLEWELLYN E
Entity Type:Individual
Prefix:
First Name:LLEWELLYN
Middle Name:E
Last Name:TERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 CADDO ST STE 6
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5307
Mailing Address - Country:US
Mailing Address - Phone:870-230-8217
Mailing Address - Fax:870-230-8201
Practice Address - Street 1:2607 CADDO ST STE 6
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5307
Practice Address - Country:US
Practice Address - Phone:870-230-8217
Practice Address - Fax:870-230-8201
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181395526Medicaid