Provider Demographics
NPI:1194185165
Name:DESTEFANO, LORELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LORELLE
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-0729
Mailing Address - Country:US
Mailing Address - Phone:276-496-4492
Mailing Address - Fax:276-496-4839
Practice Address - Street 1:319 5TH AVE
Practice Address - Street 2:
Practice Address - City:SALTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24370-3418
Practice Address - Country:US
Practice Address - Phone:276-496-4492
Practice Address - Fax:276-496-4013
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904009238101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional