Provider Demographics
NPI:1306819131
Name:MISTIC, NETTIE RUTH (LISW)
Entity Type:Individual
Prefix:
First Name:NETTIE
Middle Name:RUTH
Last Name:MISTIC
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:NETTIE
Other - Middle Name:RUTH
Other - Last Name:STURGEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:131 N EWING ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3383
Mailing Address - Country:US
Mailing Address - Phone:740-689-6700
Mailing Address - Fax:740-689-6702
Practice Address - Street 1:131 N EWING ST
Practice Address - Street 2:UNIT B
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3383
Practice Address - Country:US
Practice Address - Phone:740-689-6700
Practice Address - Fax:740-689-6702
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0001796104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI 0001796OtherLICENSE NUMBER
OH000000387062OtherANTHEM BCBS
OH000000387062OtherANTHEM BCBS