Provider Demographics
NPI:1114565678
Name:DEFELICE, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DEFELICE
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 1:130 LINDEN TREE RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-1616
Mailing Address - Country:US
Mailing Address - Phone:914-636-4466
Mailing Address - Fax:
Practice Address - Street 1:140A SUITE 2 LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801
Practice Address - Country:US
Practice Address - Phone:914-636-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9656-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist