Basic Information
| Provider Information | |||||||||
| NPI: | 1548726706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RISTER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | PRESTENBACH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703606304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858793966 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703606304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858793966 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 12495 | LA | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | 12495 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.