Provider Demographics
NPI:1518071331
Name:PERILLO, TACEY ANNE (LMFT)
Entity Type:Individual
Prefix:
First Name:TACEY
Middle Name:ANNE
Last Name:PERILLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4081
Mailing Address - Country:US
Mailing Address - Phone:864-223-8331
Mailing Address - Fax:
Practice Address - Street 1:1547 PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-223-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4477106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3340Medicare ID - Type Unspecified