Provider Demographics
NPI:1720599756
Name:TERRY, LATANEIL
Entity type:Individual
Prefix:
First Name:LATANEIL
Middle Name:
Last Name:TERRY
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 1:3120 MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5111
Mailing Address - Country:US
Mailing Address - Phone:318-364-0741
Mailing Address - Fax:
Practice Address - Street 1:3120 MONTANA ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5111
Practice Address - Country:US
Practice Address - Phone:318-364-0741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health