Provider Demographics
NPI:1548486178
Name:BISTNER, CECELIA CHAREST (MS, CCC)
Entity type:Individual
Prefix:MS
First Name:CECELIA
Middle Name:CHAREST
Last Name:BISTNER
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 SARATOGA LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-3014
Mailing Address - Country:US
Mailing Address - Phone:763-550-1123
Mailing Address - Fax:763-550-9502
Practice Address - Street 1:4910 SARATOGA LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-3014
Practice Address - Country:US
Practice Address - Phone:763-550-1123
Practice Address - Fax:763-550-9502
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8G315BIOtherBLUE CROSS BLUE SHIELD
MN4600783OtherMEDICA PROVIDER ID