Healthcare Provider Details

I. General information

NPI: 1558485185
Provider Name (Legal Business Name): MS. DONNA MARIE DEFAZIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 CALIFORNIA TER
PASADENA CA
91105-2450
US

IV. Provider business mailing address

453 CALIFORNIA TER
PASADENA CA
91105-2450
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-7958
  • Fax: 626-795-7710
Mailing address:
  • Phone: 626-795-7958
  • Fax: 626-795-7710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: