Provider Demographics
NPI:1447721063
Name:DEFRISCO, AUDREY NAOMI (MS)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:NAOMI
Last Name:DEFRISCO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:NAOMI
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:441 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-305-3695
Mailing Address - Fax:805-543-0859
Practice Address - Street 1:441 MARSH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-305-3695
Practice Address - Fax:805-543-0859
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110475106H00000X
CALMFT132113103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist