=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871790121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WARREN WILLIAM SIBILLA JR. PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 E JEFFERSON BLVD SUITE 500
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-232-4453
-----------------------------------------------------
Fax | 574-232-7718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 E JEFFERSON BLVD SUITE 500
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-232-4453
-----------------------------------------------------
Fax | 574-232-7718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20040799
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------