Healthcare Provider Details

I. General information

NPI: 1821077520
Provider Name (Legal Business Name): LEONARD CLARK PERRY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DR 45 MDOS/SGOH
PATRICK AFB FL
32925
US

IV. Provider business mailing address

1381 S PATRICK DR 45 MDOS/SGOH
PATRICK AFB FL
32925
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8171
  • Fax: 321-494-8074
Mailing address:
  • Phone: 321-494-8171
  • Fax: 321-494-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801020940
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: