Provider Demographics
NPI:1528413192
Name:DISTEFANO, LAINE M (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:LAINE
Middle Name:M
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 PRESTON RD FL 3
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6332
Mailing Address - Country:US
Mailing Address - Phone:310-926-2446
Mailing Address - Fax:
Practice Address - Street 1:5351 SAMUELL BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6720
Practice Address - Country:US
Practice Address - Phone:214-818-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist