Provider Demographics
NPI:1003083635
Name:DISTEFANO, MATTHEW JOHN (MA, NCC, LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 ANTIETAM DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-9005
Mailing Address - Country:US
Mailing Address - Phone:304-904-0740
Mailing Address - Fax:
Practice Address - Street 1:150 PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2354
Practice Address - Country:US
Practice Address - Phone:724-415-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005413101YP2500X
WV2037101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional