Provider Demographics
NPI:1336374925
Name:DEFAZIO, LISA M (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6125 GREEN BAY RD
Mailing Address - Street 2:STE 700
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2928
Mailing Address - Country:US
Mailing Address - Phone:262-654-0487
Mailing Address - Fax:262-654-2434
Practice Address - Street 1:3734 7TH AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5525
Practice Address - Country:US
Practice Address - Phone:262-654-0487
Practice Address - Fax:262-654-2434
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7524-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical