=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033390364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA LYNN TERRY LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 DESIARD ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-3913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-345-8200
-----------------------------------------------------
Fax | 318-342-8049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 DESIARD ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-3913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-345-8200
-----------------------------------------------------
Fax | 318-342-8049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT 1003
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------