Provider Demographics
NPI:1922530070
Name:TERRY, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TERRY
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 1:7314 FOREST STRM
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4825
Mailing Address - Country:US
Mailing Address - Phone:210-248-8138
Mailing Address - Fax:
Practice Address - Street 1:433 KITTY HAWK RD
Practice Address - Street 2:STE. 219
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3357
Practice Address - Country:US
Practice Address - Phone:210-566-1280
Practice Address - Fax:210-579-8533
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73396101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional