Provider Demographics
NPI:1720546260
Name:DISTEFANO, MARISA (LPC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CUTLASS RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2911
Mailing Address - Country:US
Mailing Address - Phone:201-446-4669
Mailing Address - Fax:
Practice Address - Street 1:172 FRANKLIN AVE STE 4B
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3229
Practice Address - Country:US
Practice Address - Phone:201-446-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00661500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health