Healthcare Provider Details

I. General information

NPI: 1891313656
Provider Name (Legal Business Name): KAYLA FAZZARI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 W FOREST HOME AVE # 400
MILWAUKEE WI
53204-3228
US

IV. Provider business mailing address

1432 W FOREST HOME AVE STE 400
MILWAUKEE WI
53204-3228
US

V. Phone/Fax

Practice location:
  • Phone: 414-567-5400
  • Fax: 414-567-5359
Mailing address:
  • Phone: 414-567-5400
  • Fax: 414-567-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18558-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7720-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: