Provider Demographics
NPI:1306141742
Name:KISTNER, TRACEY ROCHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ROCHELLE
Last Name:KISTNER
Suffix:
Gender:F
Credentials:LMFT
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 111
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-0111
Mailing Address - Country:US
Mailing Address - Phone:952-807-6534
Mailing Address - Fax:
Practice Address - Street 1:9352 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-9422
Practice Address - Country:US
Practice Address - Phone:952-955-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1734106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306141742Medicaid