Basic Information
| Provider Information | |||||||||
| NPI: | 1245687516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MICKAELA | ||||||||
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| OtherLastName: | MAXEY | ||||||||
| OtherFirstName: | MICKAELA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2521 N ELMS RD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484339423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664983909 | ||||||||
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| Practice Location | |||||||||
| Address1: | 623 W WARWICK DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898606119 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2016 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 103K00000X | 1-17-28180 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.