Provider Demographics
NPI:1699523019
Name:FATE, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5136
Practice Address - Country:US
Practice Address - Phone:619-363-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician