Provider Demographics
NPI:1851468383
Name:ROTH PERREAULT, TERRY (LPC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:ROTH PERREAULT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:LEE
Other - Last Name:PERREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:33 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-2013
Mailing Address - Country:US
Mailing Address - Phone:860-224-9985
Mailing Address - Fax:860-826-4995
Practice Address - Street 1:33 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2013
Practice Address - Country:US
Practice Address - Phone:860-224-9985
Practice Address - Fax:860-826-4995
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC0000327101YM0800X
CT001640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000035004Medicaid