=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972221844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRILL THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2022
-----------------------------------------------------
Last Update Date | 08/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 OAK ST STE 201
-----------------------------------------------------
City | MASHPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02649-3135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-612-8503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 BELFAST LN
-----------------------------------------------------
City | MASHPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02649-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-612-8503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEVIN TERRILL
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 508-612-8503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------