Provider Demographics
NPI:1447447511
Name:FUGAZZI, ALISSA JAN STEIN (LCSW)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:JAN STEIN
Last Name:FUGAZZI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001B 32ND AVE S STE 2B
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6068
Mailing Address - Country:US
Mailing Address - Phone:701-747-0770
Mailing Address - Fax:701-425-0524
Practice Address - Street 1:3001B 32ND AVE S STE 2B
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6068
Practice Address - Country:US
Practice Address - Phone:701-747-0770
Practice Address - Fax:701-425-0524
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND36641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457035Medicaid