Provider Demographics
NPI:1861963779
Name:TERRELL, GREGORY MICHAEL JR
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:TERRELL
Suffix:JR
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 1:1615 OLIVE ST NE APT 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2738
Mailing Address - Country:US
Mailing Address - Phone:202-459-3357
Mailing Address - Fax:
Practice Address - Street 1:1615 OLIVE ST NE APT 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2738
Practice Address - Country:US
Practice Address - Phone:202-459-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70088527Medicaid