Provider Demographics
NPI:1194532861
Name:MARISA P DISTEFANO LPC LLC
Entity type:Organization
Organization Name:MARISA P DISTEFANO LPC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:201-446-4669
Mailing Address - Street 1:172 FRANKLIN AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3229
Mailing Address - Country:US
Mailing Address - Phone:201-446-4669
Mailing Address - Fax:
Practice Address - Street 1:172 FRANKLIN AVE STE 4B
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3229
Practice Address - Country:US
Practice Address - Phone:201-446-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty