Provider Demographics
NPI:1760588818
Name:PERRY, LEE LEGRAND (LCSW)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:LEGRAND
Last Name:PERRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5149 S 1500 W STE 180
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-3926
Mailing Address - Country:US
Mailing Address - Phone:801-475-0402
Mailing Address - Fax:801-475-7464
Practice Address - Street 1:5149 S 1500 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3926
Practice Address - Country:US
Practice Address - Phone:801-475-0402
Practice Address - Fax:801-475-7464
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59746953502104100000X
UT5974695-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6Medicaid