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General NPI Number Information
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NPI Number | 1124989298
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Entity Type | Individual
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Provider Name | MS. AVERY JANE FASULO
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Gender | Female
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Dates
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Enumeration Date | 11/19/2025
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 6465 1ST AVE S
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City | SAINT PETERSBURG
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State | FL
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Zip | 33707-1301
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Country | US
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Telephone | 813-324-5730
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Fax | 727-499-5880
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Provider Business Mailing Address
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Address Line | 226 22ND AVE N APT 2
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City | SAINT PETERSBURG
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State | FL
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Zip | 33704-4428
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | BACB1378482
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License Number State | FL
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