Provider Demographics
NPI:1922692896
Name:TERRY, IDA M
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:M
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 1:623 SEDGEWICK DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-3207
Mailing Address - Country:US
Mailing Address - Phone:860-325-2963
Mailing Address - Fax:
Practice Address - Street 1:623 SEDGEWICK DR
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:DE
Practice Address - Zip Code:19962-3207
Practice Address - Country:US
Practice Address - Phone:860-325-2863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-11055101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health