Provider Demographics
NPI:1659039329
Name:DALISO, CHRISTY ANNE
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:ANNE
Last Name:DALISO
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 1:4647 CLYDE MORRIS BLVD. SUITE 501
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3001
Mailing Address - Country:US
Mailing Address - Phone:386-767-3752
Mailing Address - Fax:
Practice Address - Street 1:4647 CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3000
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017604200Medicaid