Provider Demographics
NPI:1558707489
Name:PERRY, REGINALD A
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:A
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 1:304 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-4312
Mailing Address - Country:US
Mailing Address - Phone:918-845-1193
Mailing Address - Fax:
Practice Address - Street 1:304 S 4TH ST
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4312
Practice Address - Country:US
Practice Address - Phone:918-845-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-19
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health