Provider Demographics
NPI:1619759362
Name:FISETTE, CHARLIE (LMFT)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:FISETTE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 NW 23RD BLVD APT 155
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2929
Mailing Address - Country:US
Mailing Address - Phone:386-717-8472
Mailing Address - Fax:
Practice Address - Street 1:17011 STATE ROAD 50 STE 301
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8203
Practice Address - Country:US
Practice Address - Phone:833-769-3524
Practice Address - Fax:352-432-0106
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist