Provider Demographics
NPI:1144789819
Name:FRASIK, MADELINE MARIE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:MARIE
Last Name:FRASIK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 GENEVA DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-9559
Mailing Address - Country:US
Mailing Address - Phone:810-210-2616
Mailing Address - Fax:
Practice Address - Street 1:2228 GENEVA DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-9559
Practice Address - Country:US
Practice Address - Phone:810-210-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2023-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
FL1-23-64244103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other