Healthcare Provider Details

I. General information

NPI: 1093629636
Provider Name (Legal Business Name): TABITHA DEFAZIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 REDPATH ST
KELSO WA
98626-3737
US

IV. Provider business mailing address

602 S 6TH AVE APT 4
KELSO WA
98626-2500
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLPI.SI.70130074
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: