Provider Demographics
NPI:1871631945
Name:DIBIASIE, MICHAEL LOUIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:DIBIASIE
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 1:101 WIND HAVEN DR # A
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8035
Mailing Address - Country:US
Mailing Address - Phone:858-536-2015
Mailing Address - Fax:859-309-0895
Practice Address - Street 1:101 WIND HAVEN DR # A
Practice Address - Street 2:104
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8035
Practice Address - Country:US
Practice Address - Phone:859-536-2015
Practice Address - Fax:859-309-0895
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP00211Medicare PIN