Provider Demographics
NPI:1316583347
Name:DESTEFANO, BRENNA NATALIA (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:NATALIA
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 VINCELLETTE ST UNIT 103
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2267
Mailing Address - Country:US
Mailing Address - Phone:570-640-4194
Mailing Address - Fax:
Practice Address - Street 1:396 DANBURY RD STE 2A
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-2024
Practice Address - Country:US
Practice Address - Phone:203-422-2193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024161225X00000X
CT5274225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5274OtherCONNECTICUT DEPARTMENT OF PUBLIC HEALTH
NY024161OtherNY STATE EDUCATION DEPARTMENT OFFICE OF PROFESSION