Provider Demographics
NPI:1922544097
Name:PERDUE, LISA GALE (GSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GALE
Last Name:PERDUE
Suffix:
Gender:F
Credentials:GSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:30 GRIZZLEY LN
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9736
Practice Address - Country:US
Practice Address - Phone:304-574-2905
Practice Address - Fax:304-469-2981
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00940486104100000X
WVDP009404861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker