Provider Demographics
NPI:1548822281
Name:ICE, MICHAEL W (BCBA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:ICE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 KALEY PL
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7319
Mailing Address - Country:US
Mailing Address - Phone:321-987-2929
Mailing Address - Fax:
Practice Address - Street 1:2084 MEADOWLANE AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4950
Practice Address - Country:US
Practice Address - Phone:321-209-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101427200Medicaid