Provider Demographics
NPI:1316002611
Name:DISTASI, ELAINE G (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:G
Last Name:DISTASI
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 E 86TH ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2175
Mailing Address - Country:US
Mailing Address - Phone:212-722-0183
Mailing Address - Fax:212-369-9776
Practice Address - Street 1:157 E 86TH ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2175
Practice Address - Country:US
Practice Address - Phone:212-722-0183
Practice Address - Fax:212-369-9776
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050057-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN63401Medicare ID - Type Unspecified