Provider Demographics
NPI:1992082408
Name:PERCIFUL, MICHAEL DAVID (PCC-S)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:PERCIFUL
Suffix:
Gender:M
Credentials:PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8820 COMMERCE LOOP DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-2121
Mailing Address - Country:US
Mailing Address - Phone:614-880-9800
Mailing Address - Fax:614-880-9802
Practice Address - Street 1:8820 COMMERCE LOOP DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-2121
Practice Address - Country:US
Practice Address - Phone:614-880-9800
Practice Address - Fax:614-880-9802
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500726-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101Y00000XMedicaid