Provider Demographics
NPI:1710411467
Name:TERRELL, JOHNNIE (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHNNIE
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-4938
Mailing Address - Country:US
Mailing Address - Phone:239-214-3822
Mailing Address - Fax:
Practice Address - Street 1:1852 MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-4938
Practice Address - Country:US
Practice Address - Phone:239-214-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW11411104100000X
FLSW197941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker