Provider Demographics
NPI:1962850198
Name:DEFAZIO, ANTHONY (MA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 RT 138 SUITE 202
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719
Mailing Address - Country:US
Mailing Address - Phone:732-984-1263
Mailing Address - Fax:732-515-9159
Practice Address - Street 1:1540 RTE 138 STE 202
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-3765
Practice Address - Country:US
Practice Address - Phone:732-984-1263
Practice Address - Fax:732-515-9159
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)