Provider Demographics
NPI:1417445792
Name:FUENTES CARABALLO, MICHELLE IVETTE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IVETTE
Last Name:FUENTES CARABALLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:2701 MICHIGAN AVE STE J
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1214
Practice Address - Country:US
Practice Address - Phone:321-355-3904
Practice Address - Fax:407-255-6429
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician