Provider Demographics
NPI:1437724721
Name:LUBERISSE SR, WIDMARCK (BHCM)
Entity Type:Individual
Prefix:
First Name:WIDMARCK
Middle Name:
Last Name:LUBERISSE SR
Suffix:
Gender:M
Credentials:BHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 WILSON RIDGE DR APT 1920
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-6550
Mailing Address - Country:US
Mailing Address - Phone:305-502-8336
Mailing Address - Fax:
Practice Address - Street 1:929 WILSON RIDGE DR APT 1920
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-6550
Practice Address - Country:US
Practice Address - Phone:305-502-8336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101674251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management