Provider Demographics
NPI:1215937826
Name:RIEBSAME, WILLIAM E (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:E
Last Name:RIEBSAME
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 1:1555 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5407
Mailing Address - Country:US
Mailing Address - Phone:321-729-0870
Mailing Address - Fax:321-952-2516
Practice Address - Street 1:1555 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 104
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5407
Practice Address - Country:US
Practice Address - Phone:321-729-0870
Practice Address - Fax:321-952-2516
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004169103TF0200X, 103G00000X, 103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73442Medicare ID - Type UnspecifiedBCBS AND MEDICARE #