Provider Demographics
NPI:1891235446
Name:ANDERSON, TERRELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:ANDERSON
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 1:945 TANWORTH DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4740
Mailing Address - Country:US
Mailing Address - Phone:913-549-6838
Mailing Address - Fax:
Practice Address - Street 1:3420 HOLLOWAY ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-3522
Practice Address - Country:US
Practice Address - Phone:919-596-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC225X00000XMedicare Oscar/Certification