Provider Demographics
NPI:1760623433
Name:LUCIDO, MICHAEL JOHN (LLP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:LUCIDO
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7228 CRYSTAL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49615-9251
Mailing Address - Country:US
Mailing Address - Phone:313-268-2471
Mailing Address - Fax:
Practice Address - Street 1:1 MACDONALD DR STE B
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-4406
Practice Address - Country:US
Practice Address - Phone:231-347-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist