Healthcare Provider Details

I. General information

NPI: 1285837435
Provider Name (Legal Business Name): G. STEPHEN PERRY ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 BRECKENRIDGE LN STE 5
LOUISVILLE KY
40220-5730
US

IV. Provider business mailing address

3103 BRECKENRIDGE LN STE 5
LOUISVILLE KY
40220-5730
US

V. Phone/Fax

Practice location:
  • Phone: 502-493-7788
  • Fax:
Mailing address:
  • Phone: 502-493-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1163
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: