Provider Demographics
NPI:1770180309
Name:FAZIO, CHRISTINE DIANA (LMHC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:DIANA
Last Name:FAZIO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 95TH AVE UNIT 1E
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-1736
Mailing Address - Country:US
Mailing Address - Phone:929-314-3116
Mailing Address - Fax:
Practice Address - Street 1:10101 95TH AVE UNIT 1E
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-1736
Practice Address - Country:US
Practice Address - Phone:929-314-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00721400101YP2500X
NY007448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional