Provider Demographics
NPI:1881044162
Name:BARISA, JOHN JOSEPH (MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:BARISA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PATRICIA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1416
Mailing Address - Country:US
Mailing Address - Phone:256-541-2827
Mailing Address - Fax:256-828-8872
Practice Address - Street 1:209 PATRICIA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1416
Practice Address - Country:US
Practice Address - Phone:256-541-2827
Practice Address - Fax:256-828-8872
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1538251S00000X, 261QM0801X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083655773Medicaid
NC6107232Medicaid