Provider Demographics
NPI:1366592693
Name:DI BIASE, MARIO (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:DI BIASE
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 1:7001 WESTWIND DR STE 170
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-1778
Mailing Address - Country:US
Mailing Address - Phone:915-745-7134
Mailing Address - Fax:
Practice Address - Street 1:7149 BLACKSHEEP RUN
Practice Address - Street 2:
Practice Address - City:FT. CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37800103TC0700X
TN3803103TC0700X
IL071006045103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202713Medicare ID - Type Unspecified