Basic Information
| Provider Information | |||||||||
| NPI: | 1306141742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISTNER | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | ROCHELLE | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 1ST ST E | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553363181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528076534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9352 OAK AVE | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553879422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529554714 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2011 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1734 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1306141742 | 05 | MN | MEDICAID |