Provider Demographics
NPI:1831443720
Name:DESTEFANO, ANDREW X (DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:X
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:R
Other - Last Name:DESTEFANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:262 WILLOW AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2263
Mailing Address - Country:US
Mailing Address - Phone:617-863-7003
Mailing Address - Fax:
Practice Address - Street 1:262 WILLOW AVE APT 2
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2263
Practice Address - Country:US
Practice Address - Phone:617-863-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist