Provider Demographics
NPI:1346123346
Name:TERRY, MICHAEL DEON
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEON
Last Name:TERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 ALABAMA STREET
Mailing Address - Street 2:MDTERRY@VALDOSTA.EDU
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:470-576-2352
Mailing Address - Fax:470-576-2352
Practice Address - Street 1:815 ALABAMA STREET
Practice Address - Street 2:MDTERRY@VALDOSTA.EDU
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:470-576-2352
Practice Address - Fax:470-576-2352
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-25-430027106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician