Healthcare Provider Details

I. General information

NPI: 1043770548
Provider Name (Legal Business Name): KEVIN S PERDUE PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 05/06/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MACCORKLE AVE
SAINT ALBANS WV
25177-2073
US

IV. Provider business mailing address

2333 MACCORKLE AVE
SAINT ALBANS WV
25177-2073
US

V. Phone/Fax

Practice location:
  • Phone: 304-360-2225
  • Fax:
Mailing address:
  • Phone: 304-360-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.169622
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: