Provider Demographics
NPI:1922574334
Name:TERRY, BRIAN (NM LMT 8964)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TERRY
Suffix:
Gender:M
Credentials:NM LMT 8964
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SALAZAR ST # A
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-3642
Mailing Address - Country:US
Mailing Address - Phone:970-222-2710
Mailing Address - Fax:
Practice Address - Street 1:530 SALAZAR ST # A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-3642
Practice Address - Country:US
Practice Address - Phone:970-222-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8964225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist