Provider Demographics
NPI:1366871824
Name:PEREZ, MAURICIO (LICSW)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12020 SUNRISE BLVD E APT J107
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8017
Mailing Address - Country:US
Mailing Address - Phone:253-797-0331
Mailing Address - Fax:
Practice Address - Street 1:12020 SUNRISE BLVD E APT J107
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8017
Practice Address - Country:US
Practice Address - Phone:253-797-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW614553291041C0700X
WACO60784047390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical