Provider Demographics
NPI:1639318678
Name:BAINE, TERRY MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:MARIE
Last Name:BAINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5901
Mailing Address - Country:US
Mailing Address - Phone:405-209-6531
Mailing Address - Fax:405-799-1281
Practice Address - Street 1:219 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5901
Practice Address - Country:US
Practice Address - Phone:405-209-6531
Practice Address - Fax:405-799-1281
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-15
Last Update Date:2009-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical