Provider Demographics
NPI:1467917583
Name:DEFAZIO, DENISE (RN, LMT, CDT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:RN, LMT, CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3610
Mailing Address - Country:US
Mailing Address - Phone:631-682-9908
Mailing Address - Fax:
Practice Address - Street 1:4 SPRINGVILLE RD.
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-1170
Practice Address - Country:US
Practice Address - Phone:631-682-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015779-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist