Provider Demographics
NPI:1194408179
Name:FASICK FUMERO, ILEANA S (MSCP)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:S
Last Name:FASICK FUMERO
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALLE PRINCIPE GUILLERMO
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-5332
Mailing Address - Country:US
Mailing Address - Phone:787-300-1015
Mailing Address - Fax:
Practice Address - Street 1:1704 CALLE PARANA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-3160
Practice Address - Country:US
Practice Address - Phone:787-300-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7693103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling