Provider Demographics
NPI:1174291330
Name:DISTEFANO, PAIGE (SLP)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE APT 314
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3805
Mailing Address - Country:US
Mailing Address - Phone:718-564-0057
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE APT 314
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3805
Practice Address - Country:US
Practice Address - Phone:718-564-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5360-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist