Provider Demographics
NPI:1518516111
Name:FAZZONE, TRACY DAWN (MA, LPC, RPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:DAWN
Last Name:FAZZONE
Suffix:
Gender:F
Credentials:MA, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 FAWN BLF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1579
Mailing Address - Country:US
Mailing Address - Phone:210-861-3161
Mailing Address - Fax:
Practice Address - Street 1:1302 W BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1014
Practice Address - Country:US
Practice Address - Phone:210-861-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74588101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional