Provider Demographics
NPI:1043770548
Name:PERDUE, KEVIN S (PRSS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:PERDUE
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 MACCORKLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2073
Mailing Address - Country:US
Mailing Address - Phone:304-360-2225
Mailing Address - Fax:
Practice Address - Street 1:2333 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2073
Practice Address - Country:US
Practice Address - Phone:304-360-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHCDCA.169622101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)