Healthcare Provider Details

I. General information

NPI: 1023032216
Provider Name (Legal Business Name): PATRICIA ANN TISTAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 NEWMAN SPRINGS RD
LINCROFT NJ
07738-1426
US

IV. Provider business mailing address

517 NEWMAN SPRINGS RD
LINCROFT NJ
07738-1426
US

V. Phone/Fax

Practice location:
  • Phone: 732-530-6600
  • Fax: 732-583-7314
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3486
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: