MEDICARE: MR. MICHAEL JOHN LUCIDO LLP

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	103T00000X	Psychologist	6301012513	MI

General Provider Information

NPI Number	:	1760623433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL JOHN LUCIDO LLP

Provider Business Mailing Address
First Line	:	7228 CRYSTAL SPRINGS RD
Second Line	:
City	:	BELLAIRE
State	:	MI
Zip	:	49615-9251
Country	:	US
Telephone Number	:	313-268-2471
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MACDONALD DR STE B
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-4406
Country	:	US
Telephone Number	:	231-347-6701
Fax Number	:

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

Provider Enumeration Date	:	03/10/2009
Last Update Date	:	03/10/2009

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