Provider Demographics
NPI:1104261544
Name:FAZIO, STACY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:FAZIO
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 1:673 W RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-4825
Mailing Address - Country:US
Mailing Address - Phone:555-999-7308
Mailing Address - Fax:559-712-6282
Practice Address - Street 1:755 N PEACH AVE STE H14
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-7264
Practice Address - Country:US
Practice Address - Phone:555-999-7308
Practice Address - Fax:559-712-6282
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW193541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical