Provider Demographics
NPI:1245687516
Name:PEREZ, MICKAELA
Entity type:Individual
Prefix:
First Name:MICKAELA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICKAELA
Other - Middle Name:
Other - Last Name:MAXEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2521 N ELMS RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9423
Mailing Address - Country:US
Mailing Address - Phone:866-498-3909
Mailing Address - Fax:
Practice Address - Street 1:623 W WARWICK DR STE 2
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801
Practice Address - Country:US
Practice Address - Phone:989-860-6119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
1-17-28180103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other