Provider Demographics
NPI:1750007399
Name:KISTNER, MARISSA ANN (MED, PLPC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:KISTNER
Suffix:
Gender:F
Credentials:MED, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 MOHICAN DR
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-7371
Mailing Address - Country:US
Mailing Address - Phone:636-448-5677
Mailing Address - Fax:
Practice Address - Street 1:1000 EDGEWATER PT STE 401-405
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2954
Practice Address - Country:US
Practice Address - Phone:636-442-2612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022040479101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor