Provider Demographics
NPI:1003569625
Name:FANIZZI, ALYSSA MARIE
Entity Type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:MARIE
Last Name:FANIZZI
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 1:5415C BACKLICK RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3915
Mailing Address - Country:US
Mailing Address - Phone:703-941-1910
Mailing Address - Fax:
Practice Address - Street 1:5415C BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3915
Practice Address - Country:US
Practice Address - Phone:703-941-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699097139Medicaid