Provider Demographics
NPI:1053779421
Name:TERRI SQUIRES, LPC, FNP-C, PNP-C, APRN-RX
Entity type:Organization
Organization Name:TERRI SQUIRES, LPC, FNP-C, PNP-C, APRN-RX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:PROF
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, FNP-C, PNP-C,
Authorized Official - Phone:808-866-6533
Mailing Address - Street 1:PO BOX 3629
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-3629
Mailing Address - Country:US
Mailing Address - Phone:808-866-6533
Mailing Address - Fax:888-338-7728
Practice Address - Street 1:560 MOUNTAIN VILLAGE BLVD # 102A-B
Practice Address - Street 2:SUITE 102A-B
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-9513
Practice Address - Country:US
Practice Address - Phone:808-866-6533
Practice Address - Fax:888-338-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5346363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87485249Medicaid
COA108455Medicare UPIN