Provider Demographics
NPI:1336677541
Name:PERRY, THEADORE
Entity Type:Individual
Prefix:
First Name:THEADORE
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2822
Mailing Address - Country:US
Mailing Address - Phone:401-489-9977
Mailing Address - Fax:
Practice Address - Street 1:251 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2822
Practice Address - Country:US
Practice Address - Phone:401-489-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health