Healthcare Provider Details

I. General information

NPI: 1295673341
Provider Name (Legal Business Name): MIA MARIE DESTEFANO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ALBANY TPKE STE 4B
CANTON CT
06019-2511
US

IV. Provider business mailing address

218 NEW BRITAIN AVE APT 5
UNIONVILLE CT
06085-1272
US

V. Phone/Fax

Practice location:
  • Phone: 860-626-5110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8258
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: