Provider Demographics
NPI:1356670467
Name:KISTLER, MARILYN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KISTLER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29708 JACQUELYN DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4444
Mailing Address - Country:US
Mailing Address - Phone:734-674-9921
Mailing Address - Fax:734-525-1939
Practice Address - Street 1:33300 WARREN RD
Practice Address - Street 2:SUITE 17
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-9627
Practice Address - Country:US
Practice Address - Phone:734-331-0773
Practice Address - Fax:734-212-2120
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010853101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional