Provider Demographics
NPI:1366827875
Name:DEFAZIO, BRANDI SUE (MHA, MA, LMFT)
Entity type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:SUE
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:MHA, MA, LMFT
Other - Prefix:MS
Other - First Name:BRANDI
Other - Middle Name:SUE
Other - Last Name:SPUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12036 198TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8522
Mailing Address - Country:US
Mailing Address - Phone:425-226-0609
Mailing Address - Fax:
Practice Address - Street 1:310 3RD AVE NE STE 118
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3348
Practice Address - Country:US
Practice Address - Phone:425-894-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-26
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60595316106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist