Provider Demographics
NPI:1275676892
Name:PERDOMO, JORGE ANTONIO (LISW)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:ANTONIO
Last Name:PERDOMO
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9320
Mailing Address - Country:US
Mailing Address - Phone:864-439-7800
Mailing Address - Fax:
Practice Address - Street 1:900 GREENVILLE DRIVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697
Practice Address - Country:US
Practice Address - Phone:864-847-1818
Practice Address - Fax:864-847-5706
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7100OtherLICENSE #