Provider Demographics
NPI:1336314707
Name:WILLIAM H PETTIBON PHD PA
Entity Type:Organization
Organization Name:WILLIAM H PETTIBON PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HARRY
Authorized Official - Last Name:PETTIBON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-366-1693
Mailing Address - Street 1:6521 KEYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-7133
Mailing Address - Country:US
Mailing Address - Phone:941-922-7574
Mailing Address - Fax:941-922-7574
Practice Address - Street 1:3800 S TAMIAMI TRL UNIT 210
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6909
Practice Address - Country:US
Practice Address - Phone:941-366-1693
Practice Address - Fax:941-922-7574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6096103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty