Provider Demographics
NPI:1356521652
Name:PISTOTNIK, BLAISE (MED MA)
Entity type:Individual
Prefix:
First Name:BLAISE
Middle Name:
Last Name:PISTOTNIK
Suffix:
Gender:F
Credentials:MED MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 E FRY BLVD
Mailing Address - Street 2:APACHE MIDDLE SCHOOL
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2972
Mailing Address - Country:US
Mailing Address - Phone:520-515-2928
Mailing Address - Fax:520-515-2900
Practice Address - Street 1:3555 E FRY BLVD
Practice Address - Street 2:APACHE MIDDLE SCHOOL
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2972
Practice Address - Country:US
Practice Address - Phone:520-515-2928
Practice Address - Fax:520-515-2900
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool