Provider Demographics
NPI:1831656131
Name:TERRY, SHAQUILLA U
Entity Type:Individual
Prefix:
First Name:SHAQUILLA
Middle Name:U
Last Name:TERRY
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 1:810 BROADWAY ST, APT 5
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:617-756-9733
Mailing Address - Fax:
Practice Address - Street 1:810 BROADWAY ST, APT 5
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:617-756-9733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
106S00000XOtherKEY AUTISM
0OtherKEY AUTISM