Provider Demographics
NPI:1942452651
Name:ICE, EMILY DIANE (BCABA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:DIANE
Last Name:ICE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 AMBER AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4046
Mailing Address - Country:US
Mailing Address - Phone:907-347-8115
Mailing Address - Fax:
Practice Address - Street 1:3060 AMBER AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4046
Practice Address - Country:US
Practice Address - Phone:907-347-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst