Provider Demographics
NPI:1972325223
Name:DISTEFANO, COURTNEY MARIE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-5719
Mailing Address - Country:US
Mailing Address - Phone:727-538-8500
Mailing Address - Fax:
Practice Address - Street 1:5000 E BAY DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-5719
Practice Address - Country:US
Practice Address - Phone:727-538-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67768183500000X
AL987456A103TS0200X
LA1234103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Yes183500000XPharmacy Service ProvidersPharmacist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC123456789Medicaid