Healthcare Provider Details

I. General information

NPI: 1497689079
Provider Name (Legal Business Name): JOHN ANTHONY DESTEFANO JR. LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ROUTE 88
BRICK NJ
08724-2320
US

IV. Provider business mailing address

415 LAWRENCE DR
LANOKA HARBOR NJ
08734-2515
US

V. Phone/Fax

Practice location:
  • Phone: 732-785-1900
  • Fax:
Mailing address:
  • Phone: 732-814-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06987700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: