Provider Demographics
NPI:1225623762
Name:FAZIO, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:FAZIO
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:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0463
Mailing Address - Country:US
Mailing Address - Phone:907-460-0778
Mailing Address - Fax:
Practice Address - Street 1:133 SMITH WAY UNIT C
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8077
Practice Address - Country:US
Practice Address - Phone:907-531-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPCOP828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional