Provider Demographics
NPI:1023073434
Name:DISTASI, STEPHANIE LYNNE (MPT)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:DISTASI
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 M ST NW
Mailing Address - Street 2:APT 616
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-4365
Mailing Address - Country:US
Mailing Address - Phone:202-494-5353
Mailing Address - Fax:
Practice Address - Street 1:1112 16TH ST NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-4823
Practice Address - Country:US
Practice Address - Phone:202-223-1737
Practice Address - Fax:202-223-1738
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC20928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist