Healthcare Provider Details

I. General information

NPI: 1861556987
Provider Name (Legal Business Name): GEORGE ALLAN TERRY LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E GREEN ST
ITHACA NY
14850-5635
US

IV. Provider business mailing address

9857 CASE RD
INTERLAKEN NY
14847-9751
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-6288
  • Fax: 607-274-6280
Mailing address:
  • Phone: 607-387-4813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR046798-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: