Provider Demographics
NPI:1104562412
Name:MCKIBBEN, WILLIAM BRADLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:MCKIBBEN
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 1:3183 CRAB TRAP DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-2482
Mailing Address - Country:US
Mailing Address - Phone:770-841-8536
Mailing Address - Fax:
Practice Address - Street 1:780 DELTONA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-7128
Practice Address - Country:US
Practice Address - Phone:386-400-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health