Provider Demographics
NPI:1750003851
Name:FASANO, CALISTA MARIE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:CALISTA
Middle Name:MARIE
Last Name:FASANO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 SYCAMORE AVE APT D7
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-6145
Mailing Address - Country:US
Mailing Address - Phone:425-890-3945
Mailing Address - Fax:
Practice Address - Street 1:620 BOWERS BLVD
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77341-0001
Practice Address - Country:US
Practice Address - Phone:936-294-3532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT91432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer