Provider Demographics
NPI:1902113590
Name:DISTASIO, AMANDA M (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COUNTY CIR
Mailing Address - Street 2:MIDDLESEX BLDG
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01003-9255
Mailing Address - Country:US
Mailing Address - Phone:413-545-2337
Mailing Address - Fax:413-545-9602
Practice Address - Street 1:111 COUNTY CIR
Practice Address - Street 2:MIDDLESEX BLDG
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01003-9255
Practice Address - Country:US
Practice Address - Phone:413-545-2337
Practice Address - Fax:413-545-9602
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11228103TC1900X
NY021930103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling