Provider Demographics
NPI:1154208056
Name:DESTEFANO, GINA MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S CARSON RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2901
Mailing Address - Country:US
Mailing Address - Phone:516-241-0999
Mailing Address - Fax:
Practice Address - Street 1:129 S CARSON RD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2901
Practice Address - Country:US
Practice Address - Phone:516-241-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist