Provider Demographics
NPI:1174823843
Name:BISTLINE, SONDRA J (MS)
Entity Type:Individual
Prefix:
First Name:SONDRA
Middle Name:J
Last Name:BISTLINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:45 N. 100 E.
Mailing Address - City:FREDONIA
Mailing Address - State:AZ
Mailing Address - Zip Code:86022-0843
Mailing Address - Country:US
Mailing Address - Phone:928-606-3565
Mailing Address - Fax:928-643-6554
Practice Address - Street 1:45 NORTH 100 EAST
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:AZ
Practice Address - Zip Code:86022-0843
Practice Address - Country:US
Practice Address - Phone:928-606-3565
Practice Address - Fax:928-643-6554
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6667235Z00000X
AZSLP6667235Z00000X
UT8562432-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist