Provider Demographics
NPI:1649849217
Name:COBERLY, TERRE G
Entity type:Individual
Prefix:
First Name:TERRE
Middle Name:G
Last Name:COBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6235
Mailing Address - Country:US
Mailing Address - Phone:505-330-8220
Mailing Address - Fax:505-234-7867
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6235
Practice Address - Country:US
Practice Address - Phone:505-330-8220
Practice Address - Fax:505-234-7867
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YA0400X
CAD0208011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)