MEDICARE: KEVIN S PERDUE PRSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.169622	OH

General Provider Information

NPI Number	:	1043770548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN S PERDUE PRSS

Provider Business Mailing Address
First Line	:	2333 MACCORKLE AVE
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-2073
Country	:	US
Telephone Number	:	304-360-2225
Fax Number	:

Provider Business Practice Location Address
First Line	:	2333 MACCORKLE AVE
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-2073
Country	:	US
Telephone Number	:	304-360-2225
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	05/06/2024

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Directions to “ KEVIN S PERDUE PRSS” Practice Location

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