Healthcare Provider Details

I. General information

NPI: 1235860578
Provider Name (Legal Business Name): OLIVIA J DISTEFANO MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2765 RICHMOND HWY STE 203
STAFFORD VA
22554-8331
US

IV. Provider business mailing address

3901 WRIGHTSVILLE AVE STE 120
WILMINGTON NC
28403-6256
US

V. Phone/Fax

Practice location:
  • Phone: 540-446-5323
  • Fax:
Mailing address:
  • Phone: 910-679-8385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202011064
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30000795
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: