Provider Demographics
NPI:1447035373
Name:FAZIO, BRIAN (QMHA, CADC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FAZIO
Suffix:
Gender:M
Credentials:QMHA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 MUSKET CT
Mailing Address - Street 2:
Mailing Address - City:LACKAWAXEN
Mailing Address - State:PA
Mailing Address - Zip Code:18435-7802
Mailing Address - Country:US
Mailing Address - Phone:570-229-5744
Mailing Address - Fax:
Practice Address - Street 1:811 MUSKET CT
Practice Address - Street 2:
Practice Address - City:LACKAWAXEN
Practice Address - State:PA
Practice Address - Zip Code:18435-7802
Practice Address - Country:US
Practice Address - Phone:570-229-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty