Provider Demographics
NPI:1578182119
Name:VAN GIESON, MICHAEL KIMO
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KIMO
Last Name:VAN GIESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26633 PURDUM RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1425
Mailing Address - Country:US
Mailing Address - Phone:240-459-5169
Mailing Address - Fax:
Practice Address - Street 1:26633 PURDUM RD
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-1425
Practice Address - Country:US
Practice Address - Phone:240-459-5169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician