Provider Demographics
NPI:1275664575
Name:GRIST, JOE ROBERT SR (MED, LPC, LCDC)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:ROBERT
Last Name:GRIST
Suffix:SR
Gender:M
Credentials:MED, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MORNINGSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-3903
Mailing Address - Country:US
Mailing Address - Phone:432-523-5493
Mailing Address - Fax:432-523-6719
Practice Address - Street 1:7 MORNINGSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:TX
Practice Address - Zip Code:79714-3903
Practice Address - Country:US
Practice Address - Phone:432-523-5493
Practice Address - Fax:432-523-6719
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5495101YA0400X
TX17584101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5307LCOtherBLUE CROSS BLUE SHIELD