Provider Demographics
NPI:1962234708
Name:DEFOE, RADIE (MSCMHC)
Entity type:Individual
Prefix:
First Name:RADIE
Middle Name:
Last Name:DEFOE
Suffix:
Gender:F
Credentials:MSCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BENSE CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-1589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2285 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6631
Practice Address - Country:US
Practice Address - Phone:201-455-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health