Provider Demographics
NPI:1639265085
Name:TERRY, DERONDA VYNETTE (LPC)
Entity Type:Individual
Prefix:MS
First Name:DERONDA
Middle Name:VYNETTE
Last Name:TERRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:DERONDA
Other - Middle Name:VYNETTE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAC
Mailing Address - Street 1:6005 PARK AVE STE 630B
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5226
Mailing Address - Country:US
Mailing Address - Phone:901-767-1136
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE STE 630B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5226
Practice Address - Country:US
Practice Address - Phone:901-767-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X
TN101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health