Provider Demographics
NPI:1669021945
Name:MCDOUGALL, TERRY (EDS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:MCDOUGALL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 BANNER CIR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-6951
Mailing Address - Country:US
Mailing Address - Phone:720-563-1443
Mailing Address - Fax:
Practice Address - Street 1:1376 BANNER CIR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-6951
Practice Address - Country:US
Practice Address - Phone:720-563-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22025103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool