Provider Demographics
NPI:1649654336
Name:TERRELL, DAMON RENARD (LICENSED PROFESSIONA)
Entity type:Individual
Prefix:MR
First Name:DAMON
Middle Name:RENARD
Last Name:TERRELL
Suffix:
Gender:M
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22350 LUCERNE DRIVE
Mailing Address - Street 2:APT 201
Mailing Address - City:SOUTHFIEILD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:313-433-1174
Mailing Address - Fax:
Practice Address - Street 1:22350 LUCERNE DRIVE
Practice Address - Street 2:APT 201
Practice Address - City:SOUTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:313-433-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010711101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health