Provider Demographics
NPI:1932658531
Name:TERRELL, THERESA (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 THISTLE PL
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-3907
Mailing Address - Country:US
Mailing Address - Phone:720-939-0499
Mailing Address - Fax:
Practice Address - Street 1:10184 E I25 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-5445
Practice Address - Country:US
Practice Address - Phone:720-378-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist