Provider Demographics
NPI:1356757082
Name:LORRAINE D. DISTON PSYD.,PA
Entity type:Organization
Organization Name:LORRAINE D. DISTON PSYD.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DISTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-905-3794
Mailing Address - Street 1:7324 BAY HILL DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2208
Mailing Address - Country:US
Mailing Address - Phone:305-905-3794
Mailing Address - Fax:305-829-2284
Practice Address - Street 1:10305 NW 41ST ST
Practice Address - Street 2:SUITE 202
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2396
Practice Address - Country:US
Practice Address - Phone:305-905-3794
Practice Address - Fax:305-829-2284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4470103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty