Provider Demographics
NPI:1760622385
Name:FISHERO-FAZIO, CHRISTINE TRACY (BCBA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:TRACY
Last Name:FISHERO-FAZIO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3076 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9301
Mailing Address - Country:US
Mailing Address - Phone:850-227-4392
Mailing Address - Fax:
Practice Address - Street 1:1321 MCCLELLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-2041
Practice Address - Country:US
Practice Address - Phone:850-227-4392
Practice Address - Fax:850-229-6166
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10-06-3112103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst