Healthcare Provider Details

I. General information

NPI: 1356529846
Provider Name (Legal Business Name): TERIL DAVIS VIPOND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 9TH ST
CRESCENT CITY CA
95531-3432
US

IV. Provider business mailing address

14387 HIGHWAY 101 S
BROOKINGS OR
97415-8322
US

V. Phone/Fax

Practice location:
  • Phone: 707-464-4349
  • Fax: 707-464-4572
Mailing address:
  • Phone: 541-661-0130
  • Fax: 541-469-4317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3237
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: