MEDICARE: MIQUIA LIDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-25-84935	GA

General Provider Information

NPI Number	:	1073368965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIQUIA LIDE

Provider Business Mailing Address
First Line	:	4035 JOHNS CREEK PKWY, STE B
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4035 JOHNS CREEK PKWY, STE B
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024
Country	:	US
Telephone Number	:	770-881-7585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2024
Last Update Date	:	12/30/2025

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Directions to “ MIQUIA LIDE ” Practice Location

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