Provider Demographics
NPI:1922870138
Name:DISTAFANO, JOSEPHINE
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:DISTAFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18099 92ND LN N
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-5140
Mailing Address - Country:US
Mailing Address - Phone:856-310-0555
Mailing Address - Fax:
Practice Address - Street 1:4905 LANTANA RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-6915
Practice Address - Country:US
Practice Address - Phone:855-408-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)