Healthcare Provider Details

I. General information

NPI: 1023580750
Provider Name (Legal Business Name): TERRANCE DEVINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 AVENUE D
NEW YORK NY
10009-6935
US

IV. Provider business mailing address

9108 COLONIAL RD APT A7
BROOKLYN NY
11209-6126
US

V. Phone/Fax

Practice location:
  • Phone: 646-395-4405
  • Fax:
Mailing address:
  • Phone: 845-774-5074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: