Provider Demographics
NPI:1619023363
Name:MISTRETTA, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:MISTRETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1508
Practice Address - Country:US
Practice Address - Phone:607-776-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006741101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)