Provider Demographics
NPI:1821114141
Name:MISTISHEN, MARY ELIZABETH (MS SLP CCC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MISTISHEN
Suffix:
Gender:F
Credentials:MS SLP CCC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:MCCABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS SLP
Mailing Address - Street 1:11 HUGHES ST
Mailing Address - Street 2:
Mailing Address - City:NEW RINGGOLD
Mailing Address - State:PA
Mailing Address - Zip Code:17960-8547
Mailing Address - Country:US
Mailing Address - Phone:570-943-2739
Mailing Address - Fax:
Practice Address - Street 1:803 N WAHNETA ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-2422
Practice Address - Country:US
Practice Address - Phone:610-782-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL003222L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist