Provider Demographics
NPI:1740374438
Name:STANLEY, PERRY GLENN (EDD)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:GLENN
Last Name:STANLEY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 MARKET ST STE 4
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1426
Mailing Address - Country:US
Mailing Address - Phone:910-777-5575
Mailing Address - Fax:910-777-5273
Practice Address - Street 1:3825 MARKET ST STE 4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1426
Practice Address - Country:US
Practice Address - Phone:910-777-5575
Practice Address - Fax:910-777-5273
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV596103T00000X
NC6173103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164395000Medicaid
WVCP19076Medicare PIN
WVPECP33531Medicare PIN
WVCP19075Medicare PIN