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General NPI Number Information
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NPI Number | 1851478382
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Entity Type | Individual
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Provider Name | ANTOINETTE C DEFAZIO PH.D
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Gender | Female
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 07/08/2013
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Provider Practice Location Address
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Address Line | 6 TAMPA GENERAL CIR
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City | TAMPA
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State | FL
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Zip | 33606-3571
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Country | US
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Telephone | 813-844-3541
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1289
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City | TAMPA
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State | FL
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Zip | 33601-1289
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Country | US
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Telephone | 813-835-8069
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 1613
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PY6666
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY6666
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License Number State | FL
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