Basic Information
| Provider Information | |||||||||
| NPI: | 1528227519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONNELL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284720425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106410600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4276 LEGEND AVENUE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283031965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108670545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180005464 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1424 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6112106 | 05 | NC | MEDICAID |