MEDICARE: LYNN S DESTEFANO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1480	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650024090	OTHER	SC	PHYSICAL THERAPIST/ RR#

General Provider Information

NPI Number	:	1699794164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN S DESTEFANO PT

Provider Business Mailing Address
First Line	:	1476 LONG GROVE DR
Second Line	:	STE 1
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-7571
Country	:	US
Telephone Number	:	843-406-6302
Fax Number	:	843-406-6540

Provider Business Practice Location Address
First Line	:	1 BISHOP GADSDEN WAY
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-3506
Country	:	US
Telephone Number	:	843-406-6302
Fax Number	:	843-406-6540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/18/2017

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