Healthcare Provider Details

I. General information

NPI: 1205765534
Provider Name (Legal Business Name): TERRELL DEJUAN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 SALEM AVE
DAYTON OH
45406-5043
US

IV. Provider business mailing address

1212 SALEM AVE
DAYTON OH
45406-5043
US

V. Phone/Fax

Practice location:
  • Phone: 937-977-4624
  • Fax: 937-977-4624
Mailing address:
  • Phone: 937-977-4624
  • Fax: 937-977-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S0000X
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: