Provider Demographics
NPI:1215482864
Name:FAZIO, KYLE (EDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FAZIO
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1429
Mailing Address - Country:US
Mailing Address - Phone:216-692-0086
Mailing Address - Fax:
Practice Address - Street 1:447 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1429
Practice Address - Country:US
Practice Address - Phone:216-692-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21303355103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool