Provider Demographics
NPI:1700365863
Name:DISTEFANO, TEAH MAY (MA)
Entity Type:Individual
Prefix:
First Name:TEAH
Middle Name:MAY
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:TEAH
Other - Middle Name:MAY
Other - Last Name:MCCONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4515 MEYERS AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-5964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 O ST STE C
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-5789
Practice Address - Country:US
Practice Address - Phone:707-826-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician