Provider Demographics
NPI:1750662177
Name:TERRY, DANIELLE KATHLEEN YACONO
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:KATHLEEN YACONO
Last Name:TERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:KATHLEEN
Other - Last Name:YACONO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 7739
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-0739
Mailing Address - Country:US
Mailing Address - Phone:530-573-9028
Mailing Address - Fax:
Practice Address - Street 1:606 SENECA DR
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-5345
Practice Address - Country:US
Practice Address - Phone:714-829-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW869911041C0700X
CA64906101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker