Provider Demographics
NPI:1215764634
Name:PERILLO, KIMBERLY ANN (LGPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:PERILLO
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619-2858
Mailing Address - Country:US
Mailing Address - Phone:410-231-3343
Mailing Address - Fax:
Practice Address - Street 1:1616 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2858
Practice Address - Country:US
Practice Address - Phone:410-231-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15599101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional