Basic Information
| Provider Information | |||||||||
| NPI: | 1750882114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE PERALTA | ||||||||
| FirstName: | GERSON | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2108 104TH ST S APT N302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984448105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084637520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8282 28TH CT NE STE A | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985167162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609156868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2018 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.