=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245574060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNIE FAZIO MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4575 BYRD DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-7198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-920-7841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5252 CLOUD DANCE DR
-----------------------------------------------------
City | TIMNATH
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80547-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-920-7841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | ACD.0000659
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC.0012238
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------