=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427019116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY VINCENT TERPSTRA LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2189 APD 40 SUITE #1
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37323-6597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-559-3129
-----------------------------------------------------
Fax | 423-559-3129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3290 SOMERSET DR SE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37323-0421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-559-3129
-----------------------------------------------------
Fax | 423-559-3129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1846
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5245
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------