Provider Demographics
NPI:1881991891
Name:GIST, JOAN (MA)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:GIST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2682 BUTTERNUT
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1129
Mailing Address - Country:US
Mailing Address - Phone:313-617-3033
Mailing Address - Fax:313-733-2699
Practice Address - Street 1:1852 W. GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208
Practice Address - Country:US
Practice Address - Phone:313-617-3033
Practice Address - Fax:313-733-2699
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator