Provider Demographics
NPI:1104442789
Name:TERRELL, ODELL LINDY III
Entity type:Individual
Prefix:
First Name:ODELL
Middle Name:LINDY
Last Name:TERRELL
Suffix:III
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 1:106 S CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1610
Mailing Address - Country:US
Mailing Address - Phone:336-298-1490
Mailing Address - Fax:
Practice Address - Street 1:912 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1513
Practice Address - Country:US
Practice Address - Phone:336-298-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty