Provider Demographics
NPI:1457824682
Name:DEGLIOBIZZI, MARK ANTHONY JR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:DEGLIOBIZZI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ARCADIA PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 SORRENTO DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:DE
Practice Address - Zip Code:19938-4294
Practice Address - Country:US
Practice Address - Phone:302-653-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE82734103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool