Provider Demographics
NPI:1992937734
Name:FAZZALARO, KRISTYN ANNE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTYN
Middle Name:ANNE
Last Name:FAZZALARO
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 1:7 SALT SPRAY DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5652
Mailing Address - Country:US
Mailing Address - Phone:714-319-5714
Mailing Address - Fax:
Practice Address - Street 1:242 W MAIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7723
Practice Address - Country:US
Practice Address - Phone:714-319-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 228101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical