Provider Demographics
NPI:1720474117
Name:SMITH, TERRA (CTVI)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CTVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 BURTS RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13795-1731
Mailing Address - Country:US
Mailing Address - Phone:877-426-3307
Mailing Address - Fax:607-235-3982
Practice Address - Street 1:236 BURTS RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:NY
Practice Address - Zip Code:13795-1731
Practice Address - Country:US
Practice Address - Phone:877-426-3307
Practice Address - Fax:607-775-2874
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY929979151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist