Provider Demographics
NPI:1790066165
Name:PISTOLE, MICHELLE D (PISW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:D
Last Name:PISTOLE
Suffix:
Gender:F
Credentials:PISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 COUNTY ROAD 5500
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-9302
Mailing Address - Country:US
Mailing Address - Phone:505-486-6697
Mailing Address - Fax:
Practice Address - Street 1:371 COUNTY ROAD 5500
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-9302
Practice Address - Country:US
Practice Address - Phone:505-486-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-07511101YM0800X
NMX-08775251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health