Provider Demographics
NPI:1710016902
Name:DESTEFANO, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CARRIAGE PATH
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2611
Mailing Address - Country:US
Mailing Address - Phone:516-443-9877
Mailing Address - Fax:718-777-5250
Practice Address - Street 1:3 CARRIAGE PATH
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2611
Practice Address - Country:US
Practice Address - Phone:631-878-8304
Practice Address - Fax:631-878-8304
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001964-1101YM0800X
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health