Provider Demographics
NPI:1285040840
Name:FAZZINO, JEFFREY
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:FAZZINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 WALDEN AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4985
Mailing Address - Country:US
Mailing Address - Phone:716-895-6700
Mailing Address - Fax:716-896-0318
Practice Address - Street 1:463 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-1811
Practice Address - Country:US
Practice Address - Phone:716-895-6700
Practice Address - Fax:716-896-0318
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249154Medicaid