Provider Demographics
NPI:1952854317
Name:BISTIS, JOHN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BISTIS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 HARTNETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2533
Mailing Address - Country:US
Mailing Address - Phone:908-209-3730
Mailing Address - Fax:
Practice Address - Street 1:3808 HARTNETT BLVD
Practice Address - Street 2:
Practice Address - City:ISLE OF PALMS
Practice Address - State:SC
Practice Address - Zip Code:29451-2533
Practice Address - Country:US
Practice Address - Phone:908-209-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4783224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant