Provider Demographics
NPI:1033580402
Name:FAZIO-LANDRUM, ANGELA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FAZIO-LANDRUM
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:PO BOX 40605
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94140-0605
Mailing Address - Country:US
Mailing Address - Phone:707-739-6336
Mailing Address - Fax:
Practice Address - Street 1:1693 POLK ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-3614
Practice Address - Country:US
Practice Address - Phone:707-739-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA599571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical