Provider Demographics
NPI:1407171556
Name:DIPIETRO, MICHAEL JOSEPH III (MS IMH 26293)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:DIPIETRO
Suffix:III
Gender:M
Credentials:MS IMH 26293
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 ROYAL DORNOCH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-4116
Mailing Address - Country:US
Mailing Address - Phone:904-349-6294
Mailing Address - Fax:
Practice Address - Street 1:406 MCINTOSH AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4834
Practice Address - Country:US
Practice Address - Phone:904-375-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26293101YM0800X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman