Healthcare Provider Details

I. General information

NPI: 1467592550
Provider Name (Legal Business Name): THERESA G. DESTITO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

445 W WALNUT ST
PASADENA CA
91103-3563
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax: 626-441-3814
Mailing address:
  • Phone: 626-441-4221
  • Fax: 626-441-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 13286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: