Provider Demographics
NPI:1972981363
Name:DIPERSICO, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DIPERSICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-8901
Mailing Address - Country:US
Mailing Address - Phone:561-904-6514
Mailing Address - Fax:
Practice Address - Street 1:1870 FOREST HILL BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-8901
Practice Address - Country:US
Practice Address - Phone:561-904-6514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health