Healthcare Provider Details

I. General information

NPI: 1518081280
Provider Name (Legal Business Name): MR. KENNETH DWAYNE PERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23700 VAN DYKE AVE
WARREN MI
48089-1600
US

IV. Provider business mailing address

58868 VIRGINIA CIR
NEW HAVEN MI
48048-2797
US

V. Phone/Fax

Practice location:
  • Phone: 586-758-6670
  • Fax: 586-758-0243
Mailing address:
  • Phone: 586-749-5266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: