Provider Demographics
NPI:1336854686
Name:PERRY, MICHALENE
Entity type:Individual
Prefix:
First Name:MICHALENE
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 BALL LOOP LOT 3
Mailing Address - Street 2:
Mailing Address - City:BALL
Mailing Address - State:LA
Mailing Address - Zip Code:71405-9416
Mailing Address - Country:US
Mailing Address - Phone:724-854-1057
Mailing Address - Fax:
Practice Address - Street 1:63 BEAVERBROOK RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1440
Practice Address - Country:US
Practice Address - Phone:986-206-0414
Practice Address - Fax:406-794-0395
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8171960101YM0800X
COLPC0022629101YM0800X
ORC10309101YM0800X
LA8763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health