Provider Demographics
NPI:1740900208
Name:XISTO, ANDREA
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:XISTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14280 BALTIMORE AVE # 1175
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5006
Mailing Address - Country:US
Mailing Address - Phone:410-777-5709
Mailing Address - Fax:
Practice Address - Street 1:14415 CANNOCK CHASE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3136
Practice Address - Country:US
Practice Address - Phone:410-777-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY200001339103TC0700X
VA0810007294103TC0700X
MD06670103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical