Provider Demographics
NPI:1104029099
Name:DESTEFANO, JAMES MICHAEL (MSW ,LSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MICHAEL
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:MSW ,LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HARBOR CT
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1697
Mailing Address - Country:US
Mailing Address - Phone:732-887-1530
Mailing Address - Fax:732-738-4208
Practice Address - Street 1:720 KING GEORGE RD
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863-1974
Practice Address - Country:US
Practice Address - Phone:732-738-4209
Practice Address - Fax:732-738-4208
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05036200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health