Provider Demographics
NPI:1154407419
Name:DEFAZIO, MICHAEL A (MSSW LICSW CADC III)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:MSSW LICSW CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 7TH AVE
Mailing Address - Street 2:STE 24
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140
Mailing Address - Country:US
Mailing Address - Phone:262-654-0487
Mailing Address - Fax:262-654-2434
Practice Address - Street 1:3734 7TH AVE
Practice Address - Street 2:STE 24
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-654-0487
Practice Address - Fax:262-654-2434
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI044101YA0400X
WI1165104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39548700Medicaid
84770Medicare ID - Type Unspecified
WI39548700Medicaid