Provider Demographics
NPI:1952315269
Name:FISTEL, AMY RENA
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RENA
Last Name:FISTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RENA
Other - Last Name:LOPYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-A
Mailing Address - Street 1:25 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1615
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:25 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1615
Practice Address - Country:US
Practice Address - Phone:617-964-6681
Practice Address - Fax:617-630-0141
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72231H00000X
RIAUD00112231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAD0149OtherBLUE CROSS BLUE SHIELD
MA5102154Medicaid
RI29016-4/411655OtherBLUE CROSS BLUE SHIELD
MA5102154Medicaid