Provider Demographics
NPI:1629085337
Name:WISTER, PHILLIP (MFT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WISTER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 215097
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821
Mailing Address - Country:US
Mailing Address - Phone:916-834-8654
Mailing Address - Fax:
Practice Address - Street 1:7996 OLD WINDING WAY STE 210
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7159
Practice Address - Country:US
Practice Address - Phone:916-834-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40578106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist