Provider Demographics
NPI:1033682596
Name:FRASER, MYLISSA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MYLISSA
Middle Name:
Last Name:FRASER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 ARBORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4242
Mailing Address - Country:US
Mailing Address - Phone:321-549-8264
Mailing Address - Fax:
Practice Address - Street 1:6280 ARBORWOOD AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4242
Practice Address - Country:US
Practice Address - Phone:321-549-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10290103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14377878OtherCAQH #