Healthcare Provider Details

I. General information

NPI: 1104459932
Provider Name (Legal Business Name): JOHNNY ROGER TERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W OGLETHORPE HWY
HINESVILLE GA
31313
US

IV. Provider business mailing address

PO BOX 1084
GLENNVILLE GA
30427-1084
US

V. Phone/Fax

Practice location:
  • Phone: 912-334-0524
  • Fax: 508-355-0524
Mailing address:
  • Phone: 912-334-0524
  • Fax: 508-355-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW001177
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: