Provider Demographics
NPI:1629207683
Name:DIFAZZIO, MELISSA LEE (MT-BC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:DIFAZZIO
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-5720
Mailing Address - Country:US
Mailing Address - Phone:630-329-0228
Mailing Address - Fax:
Practice Address - Street 1:1128 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-5720
Practice Address - Country:US
Practice Address - Phone:630-329-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist