Healthcare Provider Details

I. General information

NPI: 1548510134
Provider Name (Legal Business Name): MICHAEL JAMES MIJON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 VIA HAVARRE
MERRITT ISLAND FL
32953-2919
US

IV. Provider business mailing address

222 VIA HAVARRE
MERRITT ISLAND FL
32953-2919
US

V. Phone/Fax

Practice location:
  • Phone: 321-514-8817
  • Fax:
Mailing address:
  • Phone: 321-514-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH4290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: