Basic Information
Provider Information | |||||||||
NPI: | 1184060899 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIBILLE | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 360 PALM COAST PKWY NE | ||||||||
Address2: |   | ||||||||
City: | PALM COAST | ||||||||
State: | FL | ||||||||
PostalCode: | 321373805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9045014344 | ||||||||
FaxNumber: | 3864472161 | ||||||||
Practice Location | |||||||||
Address1: | 360 PALM COAST PKWY NE | ||||||||
Address2: |   | ||||||||
City: | PALM COAST | ||||||||
State: | FL | ||||||||
PostalCode: | 321373805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3864464101 | ||||||||
FaxNumber: | 3864472161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2013 | ||||||||
LastUpdateDate: | 06/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 21524 | FL | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 208100000X | PT21524 | FL | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | PT21524 | 01 | FL | FLORIDA BOARD OF PHYSICAL THERAPY | OTHER |