Provider Demographics
NPI:1790343960
Name:PERSLEY, DWAYNE PERRY
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:PERRY
Last Name:PERSLEY
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 1:3335 FOLSOM ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-2117
Mailing Address - Country:US
Mailing Address - Phone:626-361-0832
Mailing Address - Fax:323-604-9898
Practice Address - Street 1:3335 FOLSOM ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2117
Practice Address - Country:US
Practice Address - Phone:626-361-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR105101214101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)