Provider Demographics
NPI:1063288975
Name:UP, TERRI
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:UP
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 1:5006 NICHOLSON RD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6402
Mailing Address - Country:US
Mailing Address - Phone:360-819-9483
Mailing Address - Fax:
Practice Address - Street 1:5006 NICHOLSON RD UNIT 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6402
Practice Address - Country:US
Practice Address - Phone:360-819-9483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61462592106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician