Provider Demographics
NPI:1225644487
Name:PISTEL, BROCK LOUIS (PHD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:LOUIS
Last Name:PISTEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 DALE RD STE J-8251
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9232
Mailing Address - Country:US
Mailing Address - Phone:209-409-4078
Mailing Address - Fax:
Practice Address - Street 1:3208 FLEUR DE LIS DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9302
Practice Address - Country:US
Practice Address - Phone:209-409-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical