Provider Demographics
NPI:1669203394
Name:PERRY, ANTHONY G SR (LCDC I)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:G
Last Name:PERRY
Suffix:SR
Gender:M
Credentials:LCDC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 JOYCE LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6028
Mailing Address - Country:US
Mailing Address - Phone:785-320-1263
Mailing Address - Fax:
Practice Address - Street 1:4520 E CENTRAL TEXAS EXPY
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5626
Practice Address - Country:US
Practice Address - Phone:254-733-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65658101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)