Provider Demographics
NPI:1346418944
Name:MISTOR, BERNADINE GERALDINE (MSW,CSW)
Entity Type:Individual
Prefix:MRS
First Name:BERNADINE
Middle Name:GERALDINE
Last Name:MISTOR
Suffix:
Gender:F
Credentials:MSW,CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7466 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1433
Mailing Address - Country:US
Mailing Address - Phone:313-846-8605
Mailing Address - Fax:313-933-4770
Practice Address - Street 1:7466 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1433
Practice Address - Country:US
Practice Address - Phone:313-846-8605
Practice Address - Fax:313-933-4770
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801021277101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION69110Medicare PIN