Provider Demographics
NPI:1891703187
Name:DESTEFANO, LOUIS JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JOSEPH
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WAKELEE AVE
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1234
Mailing Address - Country:US
Mailing Address - Phone:203-735-7481
Mailing Address - Fax:
Practice Address - Street 1:203 WAKELEE AVE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1234
Practice Address - Country:US
Practice Address - Phone:203-735-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT01097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001743Medicare ID - Type Unspecified