Provider Demographics
NPI:1669862397
Name:FAZIO, CORINNE
Entity Type:Individual
Prefix:
First Name:CORINNE
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 1:1255 SW LOOP 410
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1665
Mailing Address - Country:US
Mailing Address - Phone:210-340-2627
Mailing Address - Fax:817-249-2215
Practice Address - Street 1:1255 SW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1665
Practice Address - Country:US
Practice Address - Phone:210-340-2627
Practice Address - Fax:817-249-2215
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-14-17904103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst