MEDICARE: TERRY IRVINE LPC-SUPERVISEE

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	101YM0800X	Mental Health Counselor	20974	SD

General Provider Information

NPI Number	:	1699399758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRY IRVINE LPC-SUPERVISEE

Provider Business Mailing Address
First Line	:	105 GIANTS DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8737
Country	:	US
Telephone Number	:	605-939-6700
Fax Number	:

Provider Business Practice Location Address
First Line	:	3618 CANYON LAKE DR STE 107
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3129
Country	:	US
Telephone Number	:	605-939-6700
Fax Number	:

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

Provider Enumeration Date	:	06/04/2020
Last Update Date	:	08/04/2025

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