Provider Demographics
NPI:1083958383
Name:PERCIFUL, MICHAEL SHAUN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAUN
Last Name:PERCIFUL
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 1:8908 PEMBROOKE ST
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-9291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-913-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07606103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical