Provider Demographics
NPI:1922327915
Name:DEFANTI, ELIZABETH JENNIE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JENNIE
Last Name:DEFANTI
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 1:353 EVENING STAR LN
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-2108
Mailing Address - Country:US
Mailing Address - Phone:406-586-9904
Mailing Address - Fax:
Practice Address - Street 1:353 EVENING STAR LN
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2108
Practice Address - Country:US
Practice Address - Phone:406-586-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0017525-1101YM0800X
NC6566101YP2500X
MT1415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health