Provider Demographics
NPI:1124313879
Name:ROSSILLI, CHRISTOPHER M (PSYD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:ROSSILLI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2044
Mailing Address - Country:US
Mailing Address - Phone:904-745-3618
Mailing Address - Fax:904-722-4271
Practice Address - Street 1:4565 US HIGHWAY 17 STE 106
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4822
Practice Address - Country:US
Practice Address - Phone:904-269-4559
Practice Address - Fax:904-269-4597
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8280103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFH066ZMedicare PIN
FLFH066WMedicare UPIN