Healthcare Provider Details

I. General information

NPI: 1902113590
Provider Name (Legal Business Name): AMANDA M DISTASIO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 05/03/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COUNTY CIR MIDDLESEX BLDG
AMHERST MA
01003-9255
US

IV. Provider business mailing address

111 COUNTY CIR MIDDLESEX BLDG
AMHERST MA
01003-9255
US

V. Phone/Fax

Practice location:
  • Phone: 413-545-2337
  • Fax: 413-545-9602
Mailing address:
  • Phone: 413-545-2337
  • Fax: 413-545-9602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number11228
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number021930
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: