Provider Demographics
NPI:1205479565
Name:TERRY, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2102
Mailing Address - Country:US
Mailing Address - Phone:618-670-3042
Mailing Address - Fax:
Practice Address - Street 1:9378 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3215
Practice Address - Country:US
Practice Address - Phone:314-567-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health