Healthcare Provider Details

I. General information

NPI: 1376139485
Provider Name (Legal Business Name): MICHAEL DESTEFANO CASAC-T, BSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WEST HAWTHORNE AVE 2ND FLOOR
VALLEY STREAM NY
11580-1158
US

IV. Provider business mailing address

246 N RICHMOND AVE
MASSAPEQUA NY
11758
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number35762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: