Provider Demographics
NPI:1497257943
Name:PERRY, ANTOINETTE LEE RANDALL
Entity Type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:LEE RANDALL
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 1:2110 WASHINGTON BLVD
Mailing Address - Street 2:SEQUIOA PLZ 2
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204
Mailing Address - Country:US
Mailing Address - Phone:703-228-6005
Mailing Address - Fax:
Practice Address - Street 1:2110 WASHINGTON BLVD
Practice Address - Street 2:SEQUIOA PLAZA 2
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204
Practice Address - Country:US
Practice Address - Phone:703-228-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist