Provider Demographics
NPI:1316408503
Name:PERRY, QEARA DESHAWN
Entity Type:Individual
Prefix:
First Name:QEARA
Middle Name:DESHAWN
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 1:32100 TELEGRAPH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2454
Mailing Address - Country:US
Mailing Address - Phone:248-712-4266
Mailing Address - Fax:
Practice Address - Street 1:12740 SARSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-4815
Practice Address - Country:US
Practice Address - Phone:313-283-5987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIP600707139401156F00000X
156F00000X, 103K00000X
MI0082013411158156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103344666Medicaid