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General NPI Number Information
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NPI Number | 1104459932
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Entity Type | Individual
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Provider Name | JOHNNY ROGER TERRY
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Gender | Male
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Dates
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Enumeration Date | 02/20/2020
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Last Update Date | 07/25/2023
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Provider Practice Location Address
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Address Line | 115 W OGLETHORPE HWY
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City | HINESVILLE
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State | GA
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Zip | 31313
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Country | US
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Telephone | 912-334-0524
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Fax | 508-355-0524
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Provider Business Mailing Address
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Address Line | PO BOX 1084
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City | GLENNVILLE
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State | GA
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Zip | 30427-1084
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Country | US
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Telephone | 912-334-0524
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Fax | 508-355-0524
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW001177
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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