Provider Demographics
NPI:1306100078
Name:PEREZ, MICHELLE R (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:12 N KINGSHIGHWAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1367
Mailing Address - Country:US
Mailing Address - Phone:573-547-3116
Mailing Address - Fax:
Practice Address - Street 1:12 N KINGSHIGHWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1367
Practice Address - Country:US
Practice Address - Phone:573-547-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0048071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1306100078Medicaid