Provider Demographics
NPI:1790470821
Name:DEFONCE, MELISSA (RN, LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DEFONCE
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CHAMPLAIN DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-6221
Mailing Address - Country:US
Mailing Address - Phone:914-439-2258
Mailing Address - Fax:
Practice Address - Street 1:11 CHAMPLAIN DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-6221
Practice Address - Country:US
Practice Address - Phone:914-439-2258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055714-1104100000X
NY686380163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No104100000XBehavioral Health & Social Service ProvidersSocial Worker