Provider Demographics
NPI:1891852224
Name:DISTEFANO, KATHERINE IV
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DISTEFANO
Suffix:IV
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:MCFARLANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13500 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-6909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13500 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-6909
Practice Address - Country:US
Practice Address - Phone:360-699-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
OR11090225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist