Provider Demographics
NPI:1699827808
Name:SISBARRO, MICHAEL ANTHONY (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:SISBARRO
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 1:3601 HENDRICKS AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-396-2666
Mailing Address - Fax:904-396-2698
Practice Address - Street 1:3601 HENDRICKS AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-396-2666
Practice Address - Fax:904-396-2698
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS313103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9890OtherBLUE CROSS BLUE SHIELD
9074711OtherPRIVATE HEALTH CARE SYSTE