Provider Demographics
NPI:1407682966
Name:DISTEFANO, NADINE MARY (OTR/L)
Entity type:Individual
Prefix:MS
First Name:NADINE
Middle Name:MARY
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MILFORD LN # 2D
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-7939
Mailing Address - Country:US
Mailing Address - Phone:551-427-2957
Mailing Address - Fax:
Practice Address - Street 1:240 W PASSAIC ST STE 3
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1264
Practice Address - Country:US
Practice Address - Phone:201-250-8763
Practice Address - Fax:551-209-2520
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01124300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist