Provider Demographics
NPI:1679507255
Name:KISTNER, MARILYN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:L
Last Name:KISTNER
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 1:200 STATE HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-9198
Mailing Address - Country:US
Mailing Address - Phone:570-271-4500
Mailing Address - Fax:570-271-4599
Practice Address - Street 1:200 STATE HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-9198
Practice Address - Country:US
Practice Address - Phone:570-271-4500
Practice Address - Fax:570-271-4599
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075019KALMedicare ID - Type Unspecified