Individual
JERRY GEORGE IDICULA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.ED., BCBA
Contact information
Practice address
1332 MARYLAND ST, GROSSE POINTE PARK, MI 48230
(313) 288-9458
Mailing address
1332 MARYLAND ST, GROSSE POINTE PARK, MI 48230-1006
(313) 288-9458
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
1-19-34854
MI
Other
Enumeration date
09/28/2015
Last updated
03/27/2019
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