Healthcare Provider Details

I. General information

NPI: 1548822281
Provider Name (Legal Business Name): MICHAEL W ICE BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 MEADOWLANE AVE
WEST MELBOURNE FL
32904-4950
US

IV. Provider business mailing address

812 KALEY PL
WEST MELBOURNE FL
32904-7319
US

V. Phone/Fax

Practice location:
  • Phone: 321-209-0242
  • Fax:
Mailing address:
  • Phone: 321-987-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: