Provider Demographics
NPI:1154782795
Name:DISTEFANO, BRANDEE (LPCA)
Entity type:Individual
Prefix:
First Name:BRANDEE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1536
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28680-1536
Mailing Address - Country:US
Mailing Address - Phone:828-437-3000
Mailing Address - Fax:828-437-4999
Practice Address - Street 1:617 S GREEN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655
Practice Address - Country:US
Practice Address - Phone:828-437-3000
Practice Address - Fax:828-437-4999
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NCA12052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA12052OtherLICENSE