Provider Demographics
NPI:1699826602
Name:FAZIO, BONITA E (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:E
Last Name:FAZIO
Suffix:
Gender:F
Credentials:LICSW
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 152
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0152
Mailing Address - Country:US
Mailing Address - Phone:802-748-2524
Mailing Address - Fax:802-748-2524
Practice Address - Street 1:297 SUMMER ST
Practice Address - Street 2:KINGDOM RECOVERY CENTER
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2283
Practice Address - Country:US
Practice Address - Phone:802-748-2524
Practice Address - Fax:802-748-2524
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00011041041C0700X
MA10262611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013478Medicaid
VTFAVN4175Medicare PIN