Provider Demographics
NPI:1447480538
Name:DIBACCO, JOHN PHILIP (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILIP
Last Name:DIBACCO
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 1:11811 N TATUM BLVD
Mailing Address - Street 2:P115
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1614
Mailing Address - Country:US
Mailing Address - Phone:602-953-6165
Mailing Address - Fax:
Practice Address - Street 1:11811 N TATUM BLVD
Practice Address - Street 2:P115
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1614
Practice Address - Country:US
Practice Address - Phone:602-953-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ524103TF0200X
NV131103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic