Provider Demographics
NPI:1376229153
Name:PEREZ, VIVIANA MAUREEN
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:MAUREEN
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIANA
Other - Middle Name:MAUREEN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 STATE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-943-0780
Mailing Address - Fax:
Practice Address - Street 1:711 STATE AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-943-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61462442101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor