Provider Demographics
NPI:1417173519
Name:DESTEFANO, RON (PHD)
Entity Type:Individual
Prefix:DR
First Name:RON
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 LAVERNE AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3434
Mailing Address - Country:US
Mailing Address - Phone:415-383-3489
Mailing Address - Fax:415-383-3489
Practice Address - Street 1:342 LAVERNE AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3434
Practice Address - Country:US
Practice Address - Phone:415-383-3489
Practice Address - Fax:415-383-3489
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical