Provider Demographics
NPI:1093319055
Name:MESTISHEN, LORETTA (PSYD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:MESTISHEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 POTTSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3842
Mailing Address - Country:US
Mailing Address - Phone:570-617-8452
Mailing Address - Fax:
Practice Address - Street 1:1311 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3823
Practice Address - Country:US
Practice Address - Phone:570-617-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical