Basic Information
| Provider Information | |||||||||
| NPI: | 1285040840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAZZINO | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1526 WALDEN AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7168960318 | ||||||||
| Practice Location | |||||||||
| Address1: | 463 WILLIAM ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142041811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7168960318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2014 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 02249154 | 05 | NY | MEDICAID |