Provider Demographics
NPI:1770021362
Name:TERRY, GREGORY (BA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:TERRY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-7101
Mailing Address - Country:US
Mailing Address - Phone:206-778-2939
Mailing Address - Fax:
Practice Address - Street 1:11000 LAKE CITY WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6748
Practice Address - Country:US
Practice Address - Phone:206-604-7501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60148789171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator