Provider Demographics
NPI:1225650823
Name:CASANOVA, FABIAN
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:CASANOVA
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 1:1118 E MOWRY DR APT 101
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-8170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14425 COUNTRY WALK DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-8103
Practice Address - Country:US
Practice Address - Phone:786-349-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC251240960520106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician