Provider Demographics
NPI:1497001093
Name:PISTONE, KELLY LYNN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:PISTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC
Mailing Address - Street 1:9350 DOUBLE R BLVD APT 4013
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-3845
Mailing Address - Country:US
Mailing Address - Phone:775-502-7502
Mailing Address - Fax:
Practice Address - Street 1:8255 OPAL RANCH WAY
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-7789
Practice Address - Country:US
Practice Address - Phone:775-305-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01275101YA0400X
225400000X
NV00677-C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner