Provider Demographics
NPI:1295245900
Name:DEFEO, NICHOLAS JOHN (MS, MT-BC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:DEFEO
Suffix:
Gender:M
Credentials:MS, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 MADISON ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3208
Practice Address - Country:US
Practice Address - Phone:516-695-2346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-08
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMT-BC225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist