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NPI Code Detail

MEDICARE: TIVONA LARAE PERRY

MEDICARE: TIVONA LARAE PERRY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor

General Provider Information

NPI Number : 1407259351
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIVONA LARAE PERRY
Provider Business Mailing Address
First Line : 1608 W MAIN ST
Second Line :
City : BELLEVILLE
State : IL
Zip : 62220-1513
Country : US
Telephone Number : 618-698-2529
Fax Number :
Provider Business Practice Location Address
First Line : 11650 NEW HALLS FERRY RD
Second Line :
City : FLORISSANT
State : MO
Zip : 63033-6924
Country : US
Telephone Number : 314-837-2022
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/07/2014
Last Update Date : 10/07/2014

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Directions to “ TIVONA LARAE PERRY ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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