Provider Demographics
NPI:1093090474
Name:WILLISTON, MICHAEL ANDREW (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:WILLISTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:ANDREW
Other - Last Name:HOLSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1512
Mailing Address - Country:US
Mailing Address - Phone:215-568-0860
Mailing Address - Fax:
Practice Address - Street 1:112 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1512
Practice Address - Country:US
Practice Address - Phone:215-568-0860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist