Healthcare Provider Details

I. General information

NPI: 1689656548
Provider Name (Legal Business Name): ALI H KIZILBASH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE SUITE 304
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

5153 N 9TH AVE SUITE 304
PENSACOLA FL
32504-8785
US

V. Phone/Fax

Practice location:
  • Phone: 850-484-7800
  • Fax: 850-484-7811
Mailing address:
  • Phone: 850-484-7800
  • Fax: 850-484-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY6269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: