Provider Demographics
NPI:1013408004
Name:BYLES, MARISA VICTORIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:VICTORIA
Last Name:BYLES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11761 LANIER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1261
Mailing Address - Country:US
Mailing Address - Phone:904-540-1216
Mailing Address - Fax:
Practice Address - Street 1:12443 SAN JOSE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8648
Practice Address - Country:US
Practice Address - Phone:904-515-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9588103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical