Provider Demographics
NPI:1861776288
Name:DESTEFANO, BRITA (PT, DPT, PCS)
Entity type:Individual
Prefix:
First Name:BRITA
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:PT, DPT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 S GAYLORD ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-6023
Mailing Address - Country:US
Mailing Address - Phone:512-573-4651
Mailing Address - Fax:
Practice Address - Street 1:3015 S GAYLORD ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210
Practice Address - Country:US
Practice Address - Phone:512-573-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3369225100000X
CO00121372251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188348721Medicaid