Provider Demographics
NPI:1194843839
Name:PERRY, CAROLYN DIANE
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:DIANE
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 STADIUM ST SW
Mailing Address - Street 2:P.O. BOX 3054
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4749
Mailing Address - Country:US
Mailing Address - Phone:252-243-7174
Mailing Address - Fax:252-206-7175
Practice Address - Street 1:108 STADIUM ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4749
Practice Address - Country:US
Practice Address - Phone:252-243-7174
Practice Address - Fax:252-206-7175
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC098050320600000X
NCMHL-098-050320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities