MEDICARE: ROBERT KISTLER LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	2199	MN

General Provider Information

NPI Number	:	1083044739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT KISTLER LMFT

Provider Business Mailing Address
First Line	:	1806 IVY AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-4522
Country	:	US
Telephone Number	:	612-978-3030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1806 IVY AVE E
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-4522
Country	:	US
Telephone Number	:	612-978-3030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2013
Last Update Date	:	11/16/2013

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