Provider Demographics
NPI:1851803449
Name:DISTEPHAN, RAYMOND VINCENT (MSW)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:VINCENT
Last Name:DISTEPHAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 OLD WOODS RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3630
Mailing Address - Country:US
Mailing Address - Phone:917-922-9680
Mailing Address - Fax:
Practice Address - Street 1:11 OLD WOODS RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-3630
Practice Address - Country:US
Practice Address - Phone:917-922-9680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072615-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical