Provider Demographics
NPI:1215179403
Name:DEFAZZIO, BARBARA
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:
Last Name:DEFAZZIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N PINE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2365
Mailing Address - Country:US
Mailing Address - Phone:386-473-4566
Mailing Address - Fax:
Practice Address - Street 1:503 N PINE MEADOW DR
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2365
Practice Address - Country:US
Practice Address - Phone:386-473-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMHC6336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760556100Medicaid