Provider Demographics
NPI:1104659176
Name:FAZZARE, STEPHANIE ALISE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALISE
Last Name:FAZZARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CREST ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-1833
Mailing Address - Country:US
Mailing Address - Phone:925-366-3071
Mailing Address - Fax:
Practice Address - Street 1:99 ALMADEN BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-1605
Practice Address - Country:US
Practice Address - Phone:888-833-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician