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General NPI Number Information
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NPI Number | 1568317188
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Entity Type | Individual
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Provider Name | CALISTA FAIRLY
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Gender | Female
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Dates
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Enumeration Date | 02/27/2026
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Last Update Date | 02/27/2026
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Provider Practice Location Address
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Address Line | 15 10TH ST
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City | SHALIMAR
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State | FL
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Zip | 32579-2051
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Country | US
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Telephone | 850-374-2104
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Fax |
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Provider Business Mailing Address
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Address Line | 21 HIGHLAND DR NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-4811
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Country | US
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Telephone | 850-218-0081
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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 |
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License Number State |
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