Provider Demographics
NPI:1205443942
Name:FAZENBAKER, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:FAZENBAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 W MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1541
Mailing Address - Country:US
Mailing Address - Phone:301-697-1572
Mailing Address - Fax:
Practice Address - Street 1:260 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-6345
Practice Address - Country:US
Practice Address - Phone:304-822-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA002565225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant