Provider Demographics
NPI:1568526085
Name:PERRYMAN, RANDOLPH GRAY (MED,LPC)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:GRAY
Last Name:PERRYMAN
Suffix:
Gender:M
Credentials:MED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 HARVEY TEAGUE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9247
Mailing Address - Country:US
Mailing Address - Phone:336-769-1661
Mailing Address - Fax:
Practice Address - Street 1:301 SOUTH ELM ST.
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2696
Practice Address - Country:US
Practice Address - Phone:336-883-7480
Practice Address - Fax:336-883-4015
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4208101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102801Medicaid