Provider Demographics
NPI:1174267769
Name:ELIZARRARAS, FERNANDO A
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:A
Last Name:ELIZARRARAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 17TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6098
Mailing Address - Country:US
Mailing Address - Phone:321-241-1170
Mailing Address - Fax:321-241-1171
Practice Address - Street 1:2900 17TH ST STE 2
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6098
Practice Address - Country:US
Practice Address - Phone:321-241-1170
Practice Address - Fax:321-241-1171
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician