Healthcare Provider Details

I. General information

NPI: 1962176065
Provider Name (Legal Business Name): CARISSA DANIELLE ALFONSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 FITZGERALD RD STE 3
LAKELAND FL
33813-2618
US

IV. Provider business mailing address

160 FITZGERALD RD STE 3
LAKELAND FL
33813-2618
US

V. Phone/Fax

Practice location:
  • Phone: 863-816-4253
  • Fax: 863-248-8809
Mailing address:
  • Phone: 863-816-4253
  • Fax: 863-248-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number21178626
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73508
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: