Healthcare Provider Details

I. General information

NPI: 1396996344
Provider Name (Legal Business Name): TERRIE ANNA VINCE MFTI REGISTERED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCENIC DR
MODESTO CA
95350-6131
US

IV. Provider business mailing address

2121 CARSON OAK CT
MODESTO CA
95355-1459
US

V. Phone/Fax

Practice location:
  • Phone: 209-567-4155
  • Fax:
Mailing address:
  • Phone: 209-568-6893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number69330
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103940
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: