Provider Demographics
NPI:1437876927
Name:BARTOLO, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:BARTOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7635 TIMBERLIN PARK BLVD APT 316
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6720
Mailing Address - Country:US
Mailing Address - Phone:904-687-4860
Mailing Address - Fax:
Practice Address - Street 1:150 SOUTHPARK BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5179
Practice Address - Country:US
Practice Address - Phone:904-217-3103
Practice Address - Fax:904-467-3422
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician