Provider Demographics
NPI:1912797937
Name:DESTEFANIS, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DESTEFANIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 US HIGHWAY 46 STE 101
Mailing Address - Street 2:
Mailing Address - City:MINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07803-3163
Mailing Address - Country:US
Mailing Address - Phone:973-970-9412
Mailing Address - Fax:
Practice Address - Street 1:195 US HIGHWAY 46 STE 101
Practice Address - Street 2:
Practice Address - City:MINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:07803-3163
Practice Address - Country:US
Practice Address - Phone:973-970-9412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-4708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist