Provider Demographics
NPI:1144685512
Name:TERRELL, VINCENT JACOB (PTA)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:JACOB
Last Name:TERRELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 GLENMONT DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-5082
Mailing Address - Country:US
Mailing Address - Phone:757-650-0471
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.10375225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant