Provider Demographics
NPI:1437620689
Name:DESTEFANO, NICOLE MARIE (BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SLAUSON LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3120
Mailing Address - Country:US
Mailing Address - Phone:760-803-3717
Mailing Address - Fax:
Practice Address - Street 1:400 CONTINENTAL BLVD STE 6035
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5076
Practice Address - Country:US
Practice Address - Phone:760-803-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst