Provider Demographics
NPI:1003045105
Name:REBILLOT, JOHN ROGER (M A)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROGER
Last Name:REBILLOT
Suffix:
Gender:M
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 13TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1211
Mailing Address - Country:US
Mailing Address - Phone:727-825-0751
Mailing Address - Fax:
Practice Address - Street 1:141 MACK BAYOU LOOP
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7194
Practice Address - Country:US
Practice Address - Phone:850-267-0030
Practice Address - Fax:850-267-0034
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health