Provider Demographics
NPI:1861935462
Name:SAVANNAH, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:SAVANNAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N MARKET ST
Mailing Address - Street 2:UNIT C SUITE 104
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6537
Mailing Address - Country:US
Mailing Address - Phone:318-626-5597
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTH MARKET STREET
Practice Address - Street 2:UNIT C SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-626-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA472119580101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health