Healthcare Provider Details

I. General information

NPI: 1104261544
Provider Name (Legal Business Name): STACY LYNN FAZIO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 08/28/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 N PEACH AVE STE H14
CLOVIS CA
93611-7264
US

IV. Provider business mailing address

673 W RICHMOND AVE
CLOVIS CA
93619-4825
US

V. Phone/Fax

Practice location:
  • Phone: 555-999-7308
  • Fax: 559-712-6282
Mailing address:
  • Phone: 555-999-7308
  • Fax: 559-712-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW19354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: