Provider Demographics
NPI:1699124198
Name:DISTEFANO, NANCY (LISW-S)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 SCHOONERS CV
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9011
Mailing Address - Country:US
Mailing Address - Phone:440-867-3564
Mailing Address - Fax:
Practice Address - Street 1:7230 SCHOONERS CV
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-9011
Practice Address - Country:US
Practice Address - Phone:440-867-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11016081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical