Provider Demographics
NPI:1881017242
Name:FANTAUZZI, SONIA
Entity type:Individual
Prefix:
First Name:SONIA
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 1:1513 STARBOARD ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7002
Mailing Address - Country:US
Mailing Address - Phone:315-286-2980
Mailing Address - Fax:
Practice Address - Street 1:3270 SUNTREE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7530
Practice Address - Country:US
Practice Address - Phone:321-610-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health