Provider Demographics
NPI:1578682225
Name:BISSOONDIAL, PHILIP JOSEPH (OTR/ L)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JOSEPH
Last Name:BISSOONDIAL
Suffix:
Gender:M
Credentials:OTR/ L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 GALLBERRY LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0161
Mailing Address - Country:US
Mailing Address - Phone:704-649-4509
Mailing Address - Fax:704-843-9045
Practice Address - Street 1:2300 GALLBERRY LN
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-0161
Practice Address - Country:US
Practice Address - Phone:704-649-4509
Practice Address - Fax:704-843-9045
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4874225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301563Medicaid