Provider Demographics
NPI:1245509876
Name:MISTIC, JOSHUA (DPT)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:MISTIC
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5113
Mailing Address - Country:US
Mailing Address - Phone:218-755-6360
Mailing Address - Fax:218-755-6399
Practice Address - Street 1:1217 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5113
Practice Address - Country:US
Practice Address - Phone:218-755-6360
Practice Address - Fax:218-755-6399
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2025-01-02
Deactivation Date:2019-09-22
Deactivation Code:
Reactivation Date:2022-09-29
Provider Licenses
StateLicense IDTaxonomies
MN91812251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070018894OtherSTATE LICENSE