Basic Information
| Provider Information | |||||||||
| NPI: | 1689282626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERKINSON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | KRISTIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANDLER | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | KRISTIN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 128 PLOW POINT LN | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285469591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096138016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 309 PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | BURGAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284253280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102590668 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P014709 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.