Provider Demographics
NPI:1790957074
Name:DISTEFANO, LYNDA A (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LYNDA
Middle Name:A
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 NORTH AVE
Mailing Address - Street 2:DOOR #14
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1322
Mailing Address - Country:US
Mailing Address - Phone:781-245-4446
Mailing Address - Fax:781-245-5505
Practice Address - Street 1:607 NORTH AVE
Practice Address - Street 2:DOOR #14
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1322
Practice Address - Country:US
Practice Address - Phone:781-245-4446
Practice Address - Fax:781-245-5505
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3041235Z00000X
RISP00880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
010880005OtherASHA MEMBERSHIP
RISP00880OtherSTATE LICENSE
MA3041OtherSTATE LICENSE