Provider Demographics
NPI:1174020291
Name:DISTEFANO, LINDSEY AUTUMN (MA)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:AUTUMN
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MONROE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1455
Mailing Address - Country:US
Mailing Address - Phone:616-259-2707
Mailing Address - Fax:
Practice Address - Street 1:1000 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1455
Practice Address - Country:US
Practice Address - Phone:616-259-7207
Practice Address - Fax:616-259-7261
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC0015902101Y00000X, 101YS0200X
MI6401223229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool