Jerry George Idicula, M.ED., BCBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-19-34854 Issued in MI

Practice address

1332 Maryland St
Grosse Pointe Park, MI 48230

Phone

(313) 288-9458

NPI assigned

Sep 28, 2015

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Education

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1443398400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1553644800000",
    "number": "1356711766",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1332 MARYLAND ST",
            "city": "GROSSE POINTE PARK",
            "state": "MI",
            "postal_code": "482301006",
            "telephone_number": "313-288-9458"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1332 MARYLAND ST",
            "city": "GROSSE POINTE PARK",
            "state": "MI",
            "postal_code": "48230",
            "telephone_number": "313-288-9458"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IDICULA",
        "first_name": "JERRY",
        "middle_name": "GEORGE",
        "credential": "M.ED., BCBA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-09-28",
        "last_updated": "2019-03-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "MI",
            "license": "1-19-34854",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sara Havlik
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• Behavior Analyst in Grosse Pointe Park, MI
• Providers in Grosse Pointe Park, MI by specialty
• Behavior Analyst in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.