Healthcare Provider Details

I. General information

NPI: 1922544097
Provider Name (Legal Business Name): LISA GALE PERDUE GSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 GRIZZLEY LN
SUMMERSVILLE WV
26651-9736
US

IV. Provider business mailing address

497 MALL RD
OAK HILL WV
25901-6216
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-2905
  • Fax: 304-469-2981
Mailing address:
  • Phone: 304-469-2905
  • Fax: 304-465-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00940486
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00940486
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: