Provider Demographics
NPI:1548510134
Name:MIJON, MICHAEL JAMES (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:MIJON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 VIA HAVARRE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-2919
Mailing Address - Country:US
Mailing Address - Phone:321-514-8817
Mailing Address - Fax:
Practice Address - Street 1:222 VIA HAVARRE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-2919
Practice Address - Country:US
Practice Address - Phone:321-514-8817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH4290101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4972685OtherDEPARTMENT OF HEALTH, DIVISION OF MEDICAL QUALITY ASSURANCE