Provider Demographics
NPI:1457470056
Name:KISTLER, ELAINE D (MA)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:D
Last Name:KISTLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PINKNEY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-5988
Mailing Address - Country:US
Mailing Address - Phone:704-482-3138
Mailing Address - Fax:
Practice Address - Street 1:1429 E MARION ST
Practice Address - Street 2:STE 5
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4986
Practice Address - Country:US
Practice Address - Phone:704-480-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC770103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046MEOtherBLUE CROSS & BLUE SHIELD