Provider Demographics
NPI:1346715505
Name:FAZIO, CARLY (SLP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:FAZIO
Suffix:
Gender:F
Credentials:SLP
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 9
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-0009
Mailing Address - Country:US
Mailing Address - Phone:281-354-3383
Mailing Address - Fax:
Practice Address - Street 1:23750 FM 1314 RD
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-3713
Practice Address - Country:US
Practice Address - Phone:281-354-3383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist