Provider Demographics
NPI:1538214895
Name:MISTOVICH, PAULA J (LCSW)
Entity type:Individual
Prefix:MS
First Name:PAULA
Middle Name:J
Last Name:MISTOVICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:PAULA
Other - Middle Name:J
Other - Last Name:MISTOVICH RENNICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2162 E CAIRO DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4635 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7127
Practice Address - Country:US
Practice Address - Phone:602-225-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-06531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical