Provider Demographics
NPI:1851478382
Name:DEFAZIO, ANTOINETTE C (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:C
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-835-8069
Mailing Address - Fax:
Practice Address - Street 1:6 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1613103G00000X
FLPY6666103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1613OtherPSYCHOLOGY LICENSE
FLPY 6666OtherFLORIDA PSYCHOLOGY
MD1613OtherPSYCHOLOGY LICENSE