Healthcare Provider Details

I. General information

NPI: 1003367905
Provider Name (Legal Business Name): TERRELL MONTAGUE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 WISTERIA RD
GOOSE CREEK SC
29445-3495
US

IV. Provider business mailing address

96 WISTERIA RD
GOOSE CREEK SC
29445-3495
US

V. Phone/Fax

Practice location:
  • Phone: 843-797-7871
  • Fax: 843-797-8638
Mailing address:
  • Phone: 843-797-7871
  • Fax: 843-797-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: