Provider Demographics
NPI:1265197925
Name:HALE, TERRANCE
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:HALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5988 LANCELOT LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-9016
Mailing Address - Country:US
Mailing Address - Phone:678-507-4113
Mailing Address - Fax:
Practice Address - Street 1:3500 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2315
Practice Address - Country:US
Practice Address - Phone:844-433-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251C00000X
373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003247136BMedicaid
01011975OtherDATE OF BIRTH
GA251C00000XOtherTAXONOMY CODE
GA003247136AMedicaid
GA003252348AMedicaid