Provider Demographics
NPI:1528890704
Name:DISTASO, BRIAN (LCMHC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DISTASO
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6016 STOREHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 SAM NEWELL RD STE 100
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7593
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17591101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional