Provider Demographics
NPI:1518638725
Name:SULISTIO, PHOEBE PRISCILLA
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:PRISCILLA
Last Name:SULISTIO
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 1:415 N RICHARD JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3664
Mailing Address - Country:US
Mailing Address - Phone:850-866-0441
Mailing Address - Fax:850-254-0827
Practice Address - Street 1:6125 UNIVERSITY DR NW STE B22
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-1765
Practice Address - Country:US
Practice Address - Phone:256-692-9262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-21-183500106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician