Provider Demographics
NPI:1174797633
Name:KISTNER, JUDITH ANN (MS)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:KISTNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-3218
Mailing Address - Country:US
Mailing Address - Phone:715-834-6681
Mailing Address - Fax:715-834-9954
Practice Address - Street 1:550 N DEWEY ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-3218
Practice Address - Country:US
Practice Address - Phone:715-834-6681
Practice Address - Fax:715-834-9954
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2078125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40945000Medicaid