Provider Demographics
NPI:1326050451
Name:PERRY, KERMIT CHARLES (LCSW)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:CHARLES
Last Name:PERRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:KIT
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:66 STONE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5227
Mailing Address - Country:US
Mailing Address - Phone:207-626-3455
Mailing Address - Fax:207-626-3612
Practice Address - Street 1:66 STONE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5227
Practice Address - Country:US
Practice Address - Phone:207-626-3455
Practice Address - Fax:207-626-3612
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC50851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM7679Medicare ID - Type Unspecified