MEDICARE: MR. GEORGE ALLAN TERRY LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	R046798-1	NY

General Provider Information

NPI Number	:	1861556987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE ALLAN TERRY LCSW-R

Provider Business Mailing Address
First Line	:	9857 CASE RD
Second Line	:
City	:	INTERLAKEN
State	:	NY
Zip	:	14847-9751
Country	:	US
Telephone Number	:	607-387-4813
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E GREEN ST
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-5635
Country	:	US
Telephone Number	:	607-274-6288
Fax Number	:	607-274-6280

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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