Provider Demographics
NPI:1386619211
Name:DEFAZIO, VICTOR JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:JOSEPH
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2711
Mailing Address - Country:US
Mailing Address - Phone:516-829-5227
Mailing Address - Fax:516-829-5227
Practice Address - Street 1:40 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2307
Practice Address - Country:US
Practice Address - Phone:516-829-5227
Practice Address - Fax:516-829-5227
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004382103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist