Provider Demographics
NPI:1134387897
Name:IDE, MICHAEL ALLEN (LSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:IDE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 SANDERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509
Mailing Address - Country:US
Mailing Address - Phone:570-266-1635
Mailing Address - Fax:
Practice Address - Street 1:562 WYOMING AVENUE
Practice Address - Street 2:CHOICES
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-552-3700
Practice Address - Fax:570-552-3705
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PASW129791104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)