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General NPI Number Information
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NPI Number | 1750007399
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Entity Type | Individual
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Provider Name | MARISSA ANN KISTNER M.ED., PLPC
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Gender | Female
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Dates
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Enumeration Date | 10/17/2022
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Last Update Date | 10/17/2022
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Provider Practice Location Address
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Address Line | 1000 EDGEWATER PT STE 401-405
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-2954
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Country | US
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Telephone | 636-442-2612
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Fax |
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Provider Business Mailing Address
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Address Line | 919 MOHICAN DR
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City | WARRENTON
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State | MO
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Zip | 63383-7371
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Country | US
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Telephone | 636-448-5677
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 2022040479
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License Number State | MO
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