Provider Demographics
NPI:1104326453
Name:FIALLO, MICHELLE NICOLE (LMHC, CCTP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:FIALLO
Suffix:
Gender:F
Credentials:LMHC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3292 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4357
Mailing Address - Country:US
Mailing Address - Phone:904-728-2578
Mailing Address - Fax:
Practice Address - Street 1:3292 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4357
Practice Address - Country:US
Practice Address - Phone:904-728-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health