Provider Demographics
NPI:1538536388
Name:DISTEFANO, JUSTINE MARGARET (MED)
Entity type:Individual
Prefix:MISS
First Name:JUSTINE
Middle Name:MARGARET
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LAKESIDE DR
Mailing Address - Street 2:APT #526
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-7910
Mailing Address - Country:US
Mailing Address - Phone:716-400-8109
Mailing Address - Fax:
Practice Address - Street 1:124 LAKESIDE DR
Practice Address - Street 2:APT #526
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-7910
Practice Address - Country:US
Practice Address - Phone:716-400-8109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist