Provider Demographics
NPI:1518081280
Name:PERRY, KENNETH DWAYNE
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DWAYNE
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 1:58868 VIRGINIA CIR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-2797
Mailing Address - Country:US
Mailing Address - Phone:586-749-5266
Mailing Address - Fax:
Practice Address - Street 1:23700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1600
Practice Address - Country:US
Practice Address - Phone:586-758-6670
Practice Address - Fax:586-758-0243
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM-10162 MMedicaid
MIM-10161 MMedicaid