Provider Demographics
NPI:1740326370
Name:DEFAZIO, PAUL MICHAEL (MSW)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:MICHAEL
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 7TH AVENUE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140
Mailing Address - Country:US
Mailing Address - Phone:262-654-0487
Mailing Address - Fax:262-654-2434
Practice Address - Street 1:3734 7TH AVENUE
Practice Address - Street 2:SUITE 24
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-654-0487
Practice Address - Fax:262-654-2434
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31231231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39504600Medicaid