Provider Demographics
NPI:1639495559
Name:DESTEFANO, KATHERINE ANNE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DEVINE ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2195
Mailing Address - Country:US
Mailing Address - Phone:203-287-6100
Mailing Address - Fax:203-287-6101
Practice Address - Street 1:6 DEVINE ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2195
Practice Address - Country:US
Practice Address - Phone:203-287-6100
Practice Address - Fax:203-287-6101
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT538182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology