Provider Demographics
NPI:1851444772
Name:DISTEFANO, LINDA R (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:R
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3812
Mailing Address - Country:US
Mailing Address - Phone:608-756-5555
Mailing Address - Fax:
Practice Address - Street 1:113 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3812
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical