Provider Demographics
NPI:1548535222
Name:RIST, HEATHER LEEANN (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LEEANN
Last Name:RIST
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5642
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86011-5642
Mailing Address - Country:US
Mailing Address - Phone:928-523-1552
Mailing Address - Fax:928-523-8092
Practice Address - Street 1:824 S SAN FRANCISCO ST ROOM 2601
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86011-1600
Practice Address - Country:US
Practice Address - Phone:928-523-1552
Practice Address - Fax:928-523-8092
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional