Provider Demographics
NPI:1376684134
Name:PERRY, PATRICK J (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:PERRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N MERIDIAN ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-7701
Mailing Address - Country:US
Mailing Address - Phone:317-925-1818
Mailing Address - Fax:317-924-6582
Practice Address - Street 1:2625 N MERIDIAN ST
Practice Address - Street 2:SUITE 18
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-7701
Practice Address - Country:US
Practice Address - Phone:317-925-1818
Practice Address - Fax:317-924-6582
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000072A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN167510RMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER