Provider Demographics
NPI:1083286819
Name:AMANDA DESTEFANO PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:AMANDA DESTEFANO PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-680-5724
Mailing Address - Street 1:42 CREELEY RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-2213
Mailing Address - Country:US
Mailing Address - Phone:617-680-5724
Mailing Address - Fax:
Practice Address - Street 1:73 TRAPELO RD STE 5
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-4463
Practice Address - Country:US
Practice Address - Phone:617-680-5724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health