Provider Demographics
NPI:1073136719
Name:DEFONSE, CLOSEL
Entity Type:Individual
Prefix:
First Name:CLOSEL
Middle Name:
Last Name:DEFONSE
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 1:7812 W WOOD LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-1426
Mailing Address - Country:US
Mailing Address - Phone:602-416-1944
Mailing Address - Fax:
Practice Address - Street 1:7812 W WOOD LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-1426
Practice Address - Country:US
Practice Address - Phone:310-956-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ843051441Medicaid