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General NPI Number Information
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NPI Number | 1356757082
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Entity Type | Organization
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Legal Business Name | LORRAINE D. DISTON PSYD.,PA
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Dates
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Enumeration Date | 07/02/2014
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Last Update Date | 07/16/2014
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Provider Practice Location Address
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Address Line | 10305 NW 41ST ST SUITE 202
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City | DORAL
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State | FL
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Zip | 33178-2396
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Country | US
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Telephone | 305-905-3794
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Fax | 305-829-2284
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Provider Business Mailing Address
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Address Line | 7324 BAY HILL DR
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City | HIALEAH
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State | FL
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Zip | 33015-2208
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Country | US
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Telephone | 305-905-3794
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Fax | 305-829-2284
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Authorized Official
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Title or Position | OWNER
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Name | DR. LORRAINE D DISTON
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Credential | PSYD
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Telephone | 305-905-3794
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY4470
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License Number State | FL
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