Provider Demographics
NPI:1861819955
Name:TERRELL, LAVIETTRIEA
Entity Type:Individual
Prefix:
First Name:LAVIETTRIEA
Middle Name:
Last Name:TERRELL
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 1:16647 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2848
Mailing Address - Country:US
Mailing Address - Phone:313-342-3606
Mailing Address - Fax:313-861-0413
Practice Address - Street 1:16647 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2848
Practice Address - Country:US
Practice Address - Phone:313-342-3606
Practice Address - Fax:313-861-0413
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)