Provider Demographics
NPI:1811539307
Name:TERRELL, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:TERRELL
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 1:201 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5638
Mailing Address - Country:US
Mailing Address - Phone:682-400-0305
Mailing Address - Fax:
Practice Address - Street 1:408 N 1ST ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:AR
Practice Address - Zip Code:71943-9250
Practice Address - Country:US
Practice Address - Phone:870-356-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-101561106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-101561OtherRBT LICENSE