Provider Demographics
NPI:1508642455
Name:FAZIO, ALIVIA MARIE
Entity Type:Individual
Prefix:
First Name:ALIVIA
Middle Name:MARIE
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 1:160 W BROADWAY UNIT 304
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1182
Mailing Address - Country:US
Mailing Address - Phone:978-835-8117
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:617-665-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist