Provider Demographics
NPI:1780222315
Name:FAZLOVIC, KARMELITA (CBHCMS)
Entity Type:Individual
Prefix:
First Name:KARMELITA
Middle Name:
Last Name:FAZLOVIC
Suffix:
Gender:F
Credentials:CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 RINGLING BLVD STE 124F
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-5354
Mailing Address - Country:US
Mailing Address - Phone:941-952-3999
Mailing Address - Fax:941-217-4990
Practice Address - Street 1:2831 RINGLING BLVD STE 124F
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-5354
Practice Address - Country:US
Practice Address - Phone:941-952-3999
Practice Address - Fax:941-217-4990
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL774581Medicaid