Provider Demographics
NPI:1639698111
Name:FAZIO, CARLY MARIE (LCSW, LCADC)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:MARIE
Last Name:FAZIO
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 KINGS HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2509
Mailing Address - Country:US
Mailing Address - Phone:732-359-2212
Mailing Address - Fax:
Practice Address - Street 1:18 KINGS HWY STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2509
Practice Address - Country:US
Practice Address - Phone:732-359-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2023-01-09
Deactivation Date:2021-04-16
Deactivation Code:
Reactivation Date:2021-05-13
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06278200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker