Provider Demographics
NPI:1790942357
Name:KISTER, DORTHY BAKER (MSW)
Entity Type:Individual
Prefix:MS
First Name:DORTHY
Middle Name:BAKER
Last Name:KISTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:DORTHY
Other - Middle Name:ELLEN
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1114 LANE 12
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-9555
Mailing Address - Country:US
Mailing Address - Phone:307-548-6543
Mailing Address - Fax:307-548-6565
Practice Address - Street 1:1114 LANE 12
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-9555
Practice Address - Country:US
Practice Address - Phone:307-548-6543
Practice Address - Fax:307-548-6565
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW #216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health