Provider Demographics
NPI:1114117157
Name:USITALO, ANN MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:USITALO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:PITEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJAX - PEDIATRICS RAINBOW CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-2120
Practice Address - Fax:904-244-5341
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA673759339AMedicaid
FL005470500Medicaid
FLAF007YMedicare PIN
FL005470500Medicaid