Provider Demographics
NPI:1508807835
Name:PERDUE, PENNY O (MA)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:O
Last Name:PERDUE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 4TH AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-523-8911
Mailing Address - Fax:304-523-8912
Practice Address - Street 1:845 4TH AVE
Practice Address - Street 2:STE 301
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-523-8911
Practice Address - Fax:304-523-8912
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV439103T00000X
KY41103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722758OtherBCBS
WV0163579000Medicaid