Provider Demographics
NPI:1710206404
Name:MICHIE, IDA C (LCSW)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:C
Last Name:MICHIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 BAYOU BLVD
Mailing Address - Street 2:BLDG 6
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2194
Mailing Address - Country:US
Mailing Address - Phone:904-476-0977
Mailing Address - Fax:
Practice Address - Street 1:5190 BAYOU BLVD
Practice Address - Street 2:BLDG 6
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2194
Practice Address - Country:US
Practice Address - Phone:904-476-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 97931041C0700X
WYSW 3471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY9464Medicare PIN