Provider Demographics
NPI:1609847417
Name:TERRELL, TERESA (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 7TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3834
Mailing Address - Country:US
Mailing Address - Phone:812-339-1551
Mailing Address - Fax:812-339-1551
Practice Address - Street 1:120 W 7TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3834
Practice Address - Country:US
Practice Address - Phone:812-339-1551
Practice Address - Fax:812-339-1551
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001873101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN546470TTMedicare ID - Type Unspecified