Basic Information
| Provider Information | |||||||||
| NPI: | 1104404623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESTEFANO | ||||||||
| FirstName: | ALISON | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 BOSTON AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021551375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815724555 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 BOSTON AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021551375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815724555 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2021 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 76791 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.