Provider Demographics
NPI:1639667595
Name:PERDUE, CARLEE (LCDCII 161744)
Entity Type:Individual
Prefix:
First Name:CARLEE
Middle Name:
Last Name:PERDUE
Suffix:
Gender:F
Credentials:LCDCII 161744
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-4074
Mailing Address - Country:US
Mailing Address - Phone:614-517-4648
Mailing Address - Fax:
Practice Address - Street 1:3141 MEDINA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-4222
Practice Address - Country:US
Practice Address - Phone:614-568-8236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OH161744101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)