Provider Demographics
NPI:1891331872
Name:TERRY, MICHAEL ANTON (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTON
Last Name:TERRY
Suffix:
Gender:M
Credentials:LCSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2151
Mailing Address - Country:US
Mailing Address - Phone:309-736-7170
Mailing Address - Fax:309-736-7150
Practice Address - Street 1:524 15TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-2151
Practice Address - Country:US
Practice Address - Phone:309-736-7170
Practice Address - Fax:309-736-7150
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0078511041C0700X
IL149.0116881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical