Provider Demographics
NPI:1972586444
Name:STURDIVANT, MICHAEL BRADLEY (ED S LMHC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRADLEY
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:ED S LMHC
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Mailing Address - Street 1:215 MOUNTAIN DR
Mailing Address - Street 2:EMERALD COAST COUNSELING CENTER #106
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2346
Mailing Address - Country:US
Mailing Address - Phone:850-837-9100
Mailing Address - Fax:850-837-3774
Practice Address - Street 1:215 MOUNTAIN DR
Practice Address - Street 2:EMERALD COAST COUNSELING CENTER #106
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2346
Practice Address - Country:US
Practice Address - Phone:850-837-9100
Practice Address - Fax:850-837-3774
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4672101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
460869OtherVALUE OPTIONS
FLZ8561OtherBCBS