=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891047429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIA G PERRY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2012
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1236 PARIS PIKE
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40324-9701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-370-7229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2385 RANDOLPH CT
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-2620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-605-5373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 5032
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------