Provider Demographics
NPI:1205904703
Name:WILLISTON, STEPHANIE KATE (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:KATE
Last Name:WILLISTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2522
Mailing Address - Country:US
Mailing Address - Phone:603-622-5561
Mailing Address - Fax:
Practice Address - Street 1:2013 ELM ST
Practice Address - Street 2:PASTORAL COUNSELING SERVICES
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2528
Practice Address - Country:US
Practice Address - Phone:603-627-2702
Practice Address - Fax:603-627-3643
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH987103TC0700X
NH17106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH304 20550Medicaid
NHWI RE 7399Medicare ID - Type Unspecified