Provider Demographics
NPI:1851791453
Name:LORISTIN, FABIOLA
Entity Type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:LORISTIN
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 1:14132 CHEVAL VINEYARD WAY APT 106
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7659
Mailing Address - Country:US
Mailing Address - Phone:407-760-1365
Mailing Address - Fax:
Practice Address - Street 1:801 DOUGLAS AVE STE 208
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-5206
Practice Address - Country:US
Practice Address - Phone:407-760-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker