Provider Demographics
NPI:1699188946
Name:MEDWED, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:MEDWED
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 1:206 N RANDOLPH ST
Mailing Address - Street 2:SUITE M106
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3949
Mailing Address - Country:US
Mailing Address - Phone:217-390-6819
Mailing Address - Fax:217-390-6819
Practice Address - Street 1:206 N RANDOLPH ST
Practice Address - Street 2:SUITE M106
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3949
Practice Address - Country:US
Practice Address - Phone:217-390-6819
Practice Address - Fax:217-390-6819
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008655101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health