Provider Demographics
NPI:1174703094
Name:WISTNER, CHERYL K (LISW)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:WISTNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15980 STATE ROUTE 114
Mailing Address - Street 2:
Mailing Address - City:GROVER HILL
Mailing Address - State:OH
Mailing Address - Zip Code:45849-9440
Mailing Address - Country:US
Mailing Address - Phone:419-399-3636
Mailing Address - Fax:419-399-5915
Practice Address - Street 1:501 MC DONALD PIKE
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879
Practice Address - Country:US
Practice Address - Phone:419-399-3636
Practice Address - Fax:419-399-5915
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00073131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical