Provider Demographics
NPI:1124803507
Name:DEFELICE, SUSAN JEAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:DEFELICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 COLBY AVE APT 611
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4066
Mailing Address - Country:US
Mailing Address - Phone:206-227-6615
Mailing Address - Fax:
Practice Address - Street 1:3120 COLBY AVE APT 611
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4066
Practice Address - Country:US
Practice Address - Phone:206-227-6615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician