Provider Demographics
NPI:1841437183
Name:PRINCE, TERASA ALAINE (LAC, NCC)
Entity type:Individual
Prefix:
First Name:TERASA
Middle Name:ALAINE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:TRAYCI
Other - Middle Name:
Other - Last Name:P
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4585 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3815
Mailing Address - Country:US
Mailing Address - Phone:602-695-5168
Mailing Address - Fax:
Practice Address - Street 1:1144 E MCDOWELL RD
Practice Address - Street 2:200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2664
Practice Address - Country:US
Practice Address - Phone:602-695-5168
Practice Address - Fax:602-307-5021
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-12674101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor