Provider Demographics
NPI:1104693613
Name:TERRELONGE, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:TERRELONGE
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 1:106 W WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-7206
Mailing Address - Country:US
Mailing Address - Phone:301-704-6457
Mailing Address - Fax:
Practice Address - Street 1:13121 BROOKLANE DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1514
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLG14499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health