MEDICARE: JULIE A. DEFAZIO MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	1003	ND

General Provider Information

NPI Number	:	1376722330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE A. DEFAZIO MS, CCC-SLP

Provider Business Mailing Address
First Line	:	500 UNIVERSITY AVE W
Second Line	:
City	:	MINOT
State	:	ND
Zip	:	58707-0001
Country	:	US
Telephone Number	:	701-858-3030
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 UNIVERSITY AVE W
Second Line	:
City	:	MINOT
State	:	ND
Zip	:	58707-0001
Country	:	US
Telephone Number	:	701-858-3030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2007
Last Update Date	:	10/26/2007

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