Provider Demographics
NPI:1205175544
Name:TERRY, ANN HAZEL (LMT, LR)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:HAZEL
Last Name:TERRY
Suffix:
Gender:F
Credentials:LMT, LR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 52ND AVE S STE 103
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7173
Mailing Address - Country:US
Mailing Address - Phone:701-566-2708
Mailing Address - Fax:
Practice Address - Street 1:2600 52ND AVE S STE 103
Practice Address - Street 2:C/O URBAN EDGE
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7173
Practice Address - Country:US
Practice Address - Phone:701-566-2708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRB12199173C00000X
ND1355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist