Provider Demographics
NPI:1669750139
Name:BISTRY, JOAN M (MA, NCCA)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:M
Last Name:BISTRY
Suffix:
Gender:F
Credentials:MA, NCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1206
Mailing Address - Country:US
Mailing Address - Phone:815-584-9312
Mailing Address - Fax:
Practice Address - Street 1:318 W CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1206
Practice Address - Country:US
Practice Address - Phone:815-584-9312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral