Provider Demographics
NPI:1790802312
Name:MINOR, TERRI (LBP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:MINOR
Suffix:
Gender:F
Credentials:LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28705 S 196 RD
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-6830
Mailing Address - Country:US
Mailing Address - Phone:918-623-2922
Mailing Address - Fax:918-623-9316
Practice Address - Street 1:209 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2618
Practice Address - Country:US
Practice Address - Phone:918-623-2922
Practice Address - Fax:918-623-9316
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health