Provider Demographics
NPI:1699794164
Name:DESTEFANO, LYNN S (PT)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:S
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 LONG GROVE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7571
Mailing Address - Country:US
Mailing Address - Phone:843-406-6302
Mailing Address - Fax:843-406-6540
Practice Address - Street 1:1 BISHOP GADSDEN WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3506
Practice Address - Country:US
Practice Address - Phone:843-406-6302
Practice Address - Fax:843-406-6540
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC650024090OtherPHYSICAL THERAPIST/ RR#
SC650024090OtherPHYSICAL THERAPIST/ RR#