Provider Demographics
NPI:1982159687
Name:DESTEFANO, CARMINE SALVATORE (LMSW)
Entity type:Individual
Prefix:
First Name:CARMINE
Middle Name:SALVATORE
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EBBITTS ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4844
Mailing Address - Country:US
Mailing Address - Phone:718-980-4400
Mailing Address - Fax:
Practice Address - Street 1:20 EBBITTS ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4844
Practice Address - Country:US
Practice Address - Phone:718-980-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072726104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker