Provider Demographics
NPI:1922467604
Name:DEFEO, COURTNEY (CASAC-T)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DEFEO
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 GRAND BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5750
Mailing Address - Country:US
Mailing Address - Phone:631-392-4357
Mailing Address - Fax:631-392-4358
Practice Address - Street 1:770 GRAND BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5750
Practice Address - Country:US
Practice Address - Phone:631-392-4357
Practice Address - Fax:631-392-4358
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)