Provider Demographics
NPI:1841068590
Name:PEREZ-GIBSON, MIGUEL MALONEY
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:MALONEY
Last Name:PEREZ-GIBSON
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:PO BOX 6363
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-6363
Mailing Address - Country:US
Mailing Address - Phone:360-259-7790
Mailing Address - Fax:
Practice Address - Street 1:203 4TH AVE E STE 220
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1187
Practice Address - Country:US
Practice Address - Phone:360-259-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60125648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health