Provider Demographics
NPI:1538833652
Name:KISTLER, MICHELLE ELISE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELISE
Last Name:KISTLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8121 ACKERMAN DR APT D
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-3881
Mailing Address - Country:US
Mailing Address - Phone:850-255-4779
Mailing Address - Fax:
Practice Address - Street 1:69 BAY BRIDGE DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4468
Practice Address - Country:US
Practice Address - Phone:850-988-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL186801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical