Provider Demographics
NPI:1194140533
Name:GIBSON-PARUCH, ELIZABETH (LBSW, QMHP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:GIBSON-PARUCH
Suffix:
Gender:F
Credentials:LBSW, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E WEST MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3571
Mailing Address - Country:US
Mailing Address - Phone:248-313-2900
Mailing Address - Fax:
Practice Address - Street 1:1010 E WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3571
Practice Address - Country:US
Practice Address - Phone:248-313-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086955171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XMedicaid