Provider Demographics
NPI:1629267877
Name:PETTIBON, WILLIAM HARRY (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HARRY
Last Name:PETTIBON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 KEYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-7133
Mailing Address - Country:US
Mailing Address - Phone:941-366-1693
Mailing Address - Fax:941-922-7574
Practice Address - Street 1:3800 S TAMIAMI TRL UNIT 210
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6909
Practice Address - Country:US
Practice Address - Phone:941-366-1693
Practice Address - Fax:941-922-7574
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6096103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54520Medicare PIN