Provider Demographics
NPI:1366323255
Name:TERRY, CIRCE
Entity type:Individual
Prefix:
First Name:CIRCE
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 1:1320 YNEZ PL # 1926
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11645 WILSHIRE BLVD STE 1070
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6810
Practice Address - Country:US
Practice Address - Phone:310-720-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist