Provider Demographics
NPI:1689067894
Name:PERRYMAN, STAN CARL II (AOD COUNSELOR)
Entity Type:Individual
Prefix:
First Name:STAN
Middle Name:CARL
Last Name:PERRYMAN
Suffix:II
Gender:M
Credentials:AOD COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2845
Mailing Address - Country:US
Mailing Address - Phone:310-399-9883
Mailing Address - Fax:310-399-9678
Practice Address - Street 1:717 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2845
Practice Address - Country:US
Practice Address - Phone:310-399-9883
Practice Address - Fax:310-399-9678
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP1402231454171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator