Provider Demographics
NPI:1548718117
Name:MENDENHALL, TERRELL
Entity type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:MENDENHALL
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 1:1440 HAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6532
Mailing Address - Country:US
Mailing Address - Phone:318-226-5990
Mailing Address - Fax:318-226-5994
Practice Address - Street 1:1440 HAWN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6532
Practice Address - Country:US
Practice Address - Phone:318-226-5990
Practice Address - Fax:318-226-5994
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health