Provider Demographics
NPI:1538198031
Name:SULISTIO, MARIA ELISABETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ELISABETH
Last Name:SULISTIO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WARNER AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4033
Mailing Address - Country:US
Mailing Address - Phone:714-293-2375
Mailing Address - Fax:714-369-8157
Practice Address - Street 1:5200 WARNER AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-4057
Practice Address - Country:US
Practice Address - Phone:714-293-2375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18394103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18394Medicare ID - Type Unspecified