Provider Demographics
NPI:1831548056
Name:FANTAUZZI, LIBERTAD
Entity type:Individual
Prefix:
First Name:LIBERTAD
Middle Name:
Last Name:FANTAUZZI
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 1:5747 CROWNTREE LN 302 APT 8-302
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829
Mailing Address - Country:US
Mailing Address - Phone:757-354-4107
Mailing Address - Fax:
Practice Address - Street 1:5747 CROWNTREE LN APT 8-302
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-8050
Practice Address - Country:US
Practice Address - Phone:757-354-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health