Provider Demographics
NPI:1922394410
Name:LADOW, TERRY (MS)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:LADOW
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 NEWPORT AVE
Mailing Address - Street 2:G 203
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5682
Mailing Address - Country:US
Mailing Address - Phone:714-731-6617
Mailing Address - Fax:714-731-6617
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:BLDG A 108
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:714-731-6617
Practice Address - Fax:714-731-6617
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR190311101YA0400X
CAA2006598101YA0400X
AZLISAC 11522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)