Provider Demographics
NPI:1801484175
Name:PERRY, ANDRAE JYLON
Entity type:Individual
Prefix:MR
First Name:ANDRAE
Middle Name:JYLON
Last Name:PERRY
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 1:3549 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-1990
Mailing Address - Country:US
Mailing Address - Phone:205-586-8933
Mailing Address - Fax:
Practice Address - Street 1:3549 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-1990
Practice Address - Country:US
Practice Address - Phone:205-586-8933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3064A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty