Provider Demographics
NPI:1023172269
Name:KISTLER, ROMEO S (LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:ROMEO
Middle Name:S
Last Name:KISTLER
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9263 REDWOOD RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6571
Mailing Address - Country:US
Mailing Address - Phone:801-566-0749
Mailing Address - Fax:801-566-7108
Practice Address - Street 1:9263 REDWOOD RD
Practice Address - Street 2:BUILDING B
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6571
Practice Address - Country:US
Practice Address - Phone:801-566-0749
Practice Address - Fax:801-566-7108
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6288646-6004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor