Provider Demographics
NPI:1568575272
Name:DISTAULO, RICHARD ANTHONY (LCSW, LCADC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ANTHONY
Last Name:DISTAULO
Suffix:
Gender:M
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MT. KEMBLE AVENUE
Mailing Address - Street 2:ATTN: C. LAMPRON
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07962-1978
Mailing Address - Country:US
Mailing Address - Phone:973-971-4714
Mailing Address - Fax:973-290-7585
Practice Address - Street 1:95 MOUNT KEMBLE AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-5155
Practice Address - Country:US
Practice Address - Phone:888-247-1400
Practice Address - Fax:973-290-7585
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00067600101YA0400X
NJ44SC013446001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical