Provider Demographics
NPI:1881193407
Name:DISTEFANO, CATHY (OMT)
Entity Type:Individual
Prefix:MS
First Name:CATHY
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WIMBLEDON CT
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2411
Mailing Address - Country:US
Mailing Address - Phone:516-510-1157
Mailing Address - Fax:
Practice Address - Street 1:5 WIMBLEDON CT
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2411
Practice Address - Country:US
Practice Address - Phone:516-510-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018374-1124Q00000X
NY018374124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9478748Medicaid
NY018374Medicaid
NY018374-1Medicaid
NY018374OtherOMT