Provider Demographics
NPI:1265246573
Name:FAZELY, ABDUL QASEM
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:QASEM
Last Name:FAZELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NO
Other - Middle Name:NO
Other - Last Name:NO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4730 MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4730 MARCONI AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-3554
Practice Address - Country:US
Practice Address - Phone:916-841-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1234104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker