Provider Demographics
NPI:1730852062
Name:FAZIO-EYNULLAYEVA, ROSALIE
Entity type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:
Last Name:FAZIO-EYNULLAYEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ROSALIE
Other - Middle Name:HUGHES
Other - Last Name:FAZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:60 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 FEDERAL ST STE 1400
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-2237
Practice Address - Country:US
Practice Address - Phone:324-661-7336
Practice Address - Fax:857-401-3013
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA2281341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health