Provider Demographics
NPI:1063788982
Name:VANDERGRIFT, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:VANDERGRIFT
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 1:7211 MELROSE LN
Mailing Address - Street 2:APT 41
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-5116
Mailing Address - Country:US
Mailing Address - Phone:405-605-2488
Mailing Address - Fax:
Practice Address - Street 1:5245 S I 35 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-7023
Practice Address - Country:US
Practice Address - Phone:405-482-9726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator