Provider Demographics
NPI:1760581110
Name:DISTEFANO, CAROLYNN V (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYNN
Middle Name:V
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2402
Mailing Address - Country:US
Mailing Address - Phone:201-280-0478
Mailing Address - Fax:
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-2104
Practice Address - Country:US
Practice Address - Phone:908-277-8936
Practice Address - Fax:973-325-0825
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00765300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist