Provider Demographics
NPI:1437756152
Name:DISTEFANO, CASSIDY G
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:G
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:G
Other - Last Name:DISTEFANO-TATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:112 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6217
Practice Address - Country:US
Practice Address - Phone:516-281-4018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst