Provider Demographics
NPI:1376528653
Name:KISTLER, MARIE JOANN (MS ED)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:JOANN
Last Name:KISTLER
Suffix:
Gender:F
Credentials:MS ED
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 741
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619
Mailing Address - Country:US
Mailing Address - Phone:218-759-2825
Mailing Address - Fax:218-759-2825
Practice Address - Street 1:403 4TH ST NW
Practice Address - Street 2:STE 110
Practice Address - City:BENIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-759-2825
Practice Address - Fax:218-759-2825
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical