Provider Demographics
NPI:1164789319
Name:FAZZIO, ERIN MARIE (OTA)
Entity Type:Individual
Prefix:MISS
First Name:ERIN
Middle Name:MARIE
Last Name:FAZZIO
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5854 ROUTE 96
Mailing Address - Street 2:APT.223A
Mailing Address - City:ROMULUS
Mailing Address - State:NY
Mailing Address - Zip Code:14541-9570
Mailing Address - Country:US
Mailing Address - Phone:607-403-0053
Mailing Address - Fax:
Practice Address - Street 1:5854 ROUTE 96
Practice Address - Street 2:APT.223A
Practice Address - City:ROMULUS
Practice Address - State:NY
Practice Address - Zip Code:14541-9570
Practice Address - Country:US
Practice Address - Phone:607-403-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007896-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant