MEDICARE: TERRY VANDERGRIFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1063788982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY VANDERGRIFT

Provider Business Mailing Address
First Line	:	7211 MELROSE LN
Second Line	:	APT 41
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-5116
Country	:	US
Telephone Number	:	405-605-2488
Fax Number	:

Provider Business Practice Location Address
First Line	:	5245 S I 35 SERVICE RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73129-7023
Country	:	US
Telephone Number	:	405-482-9726
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2012
Last Update Date	:	05/03/2013

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Directions to “ TERRY VANDERGRIFT ” Practice Location

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