Provider Demographics
NPI:1043909260
Name:GRIMOLIZZI-FASANO, NATALIA ANITA (MSW)
Entity Type:Individual
Prefix:
First Name:NATALIA
Middle Name:ANITA
Last Name:GRIMOLIZZI-FASANO
Suffix:
Gender:F
Credentials:MSW
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 146
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0146
Mailing Address - Country:US
Mailing Address - Phone:419-335-6122
Mailing Address - Fax:
Practice Address - Street 1:1115 N SHOOP AVE STE 1
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1857
Practice Address - Country:US
Practice Address - Phone:419-335-6122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.22079261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty