MEDICARE: CARLEE PERDUE LCDCII 161744

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	161744	OH

General Provider Information

NPI Number	:	1639667595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLEE PERDUE LCDCII 161744

Provider Business Mailing Address
First Line	:	5460 CLEVELAND AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-4074
Country	:	US
Telephone Number	:	614-517-4648
Fax Number	:

Provider Business Practice Location Address
First Line	:	3141 MEDINA AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-4222
Country	:	US
Telephone Number	:	614-568-8236
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2018
Last Update Date	:	02/23/2024

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