Provider Demographics
NPI:1578170403
Name:DEFAZIO, NICHOLAS DANIEL (LPCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DANIEL
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 WHITTIER AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2114
Mailing Address - Country:US
Mailing Address - Phone:330-575-3855
Mailing Address - Fax:
Practice Address - Street 1:1951 S GETTYSBURG AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4160
Practice Address - Country:US
Practice Address - Phone:937-496-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health