Provider Demographics
NPI:1184136046
Name:KISTHARDT, JOHN W (LMSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:KISTHARDT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 E HIGHWAY WW
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-4641
Mailing Address - Country:US
Mailing Address - Phone:660-886-2253
Mailing Address - Fax:660-886-6601
Practice Address - Street 1:1126 E HIGHWAY WW
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-4641
Practice Address - Country:US
Practice Address - Phone:660-886-2253
Practice Address - Fax:660-886-6601
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170387841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical