Provider Demographics
NPI:1457313173
Name:PISTILLI, JUDITH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:PISTILLI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7061 CORPORATE WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4245
Mailing Address - Country:US
Mailing Address - Phone:937-293-4179
Mailing Address - Fax:
Practice Address - Street 1:7061 CORPORATE WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4245
Practice Address - Country:US
Practice Address - Phone:937-293-4179
Practice Address - Fax:937-293-4179
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2383103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0351060Medicaid
OHCP01181Medicare PIN