Provider Demographics
NPI:1184738254
Name:POE, TERRY LAWRENCE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LAWRENCE
Last Name:POE
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:LAWRENCE
Other - Last Name:POE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 NICOLLET BLVD EAST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6741
Practice Address - Country:US
Practice Address - Phone:952-993-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6443103T00000X, 103T00000X
NC3354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
27853Medicare UPIN