Provider Demographics
NPI:1417960840
Name:BARISA, MARK T (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BARISA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0225
Mailing Address - Country:US
Mailing Address - Phone:469-400-6230
Mailing Address - Fax:
Practice Address - Street 1:4645 AVON LN STE 285
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-1609
Practice Address - Country:US
Practice Address - Phone:972-632-0033
Practice Address - Fax:214-501-0809
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34011103TC0700X, 103TC1900X, 103TE1100X, 103TH0004X, 103TR0400X, 103G00000X, 103TH0004X
IN20042107A103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation