Provider Demographics
NPI:1629470695
Name:TERRY, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:TERRY
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 1:15 CALVIN PL
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2450
Mailing Address - Country:US
Mailing Address - Phone:732-549-0401
Mailing Address - Fax:732-549-4446
Practice Address - Street 1:15 CALVIN PL
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2450
Practice Address - Country:US
Practice Address - Phone:732-549-0401
Practice Address - Fax:732-549-4446
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05876100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker