Provider Demographics
NPI:1699119065
Name:FAZIO, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FAZIO
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 1:140 FAWN LANE EAST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:631-896-0281
Mailing Address - Fax:
Practice Address - Street 1:140 FAWN LN E
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1329
Practice Address - Country:US
Practice Address - Phone:631-896-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services