Provider Demographics
NPI:1720432131
Name:FUMERO, NORIALYS
Entity Type:Individual
Prefix:
First Name:NORIALYS
Middle Name:
Last Name:FUMERO
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 1:644 NE LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1231
Mailing Address - Country:US
Mailing Address - Phone:305-879-0565
Mailing Address - Fax:
Practice Address - Street 1:2222 COLONIAL RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5309
Practice Address - Country:US
Practice Address - Phone:772-361-8581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X, 101YM0800X
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65-0789159Medicaid