Provider Demographics
NPI:1336970086
Name:PISTILLO, MIRA
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:PISTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 NEW TRAILS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4546
Mailing Address - Country:US
Mailing Address - Phone:281-367-1015
Mailing Address - Fax:281-367-1966
Practice Address - Street 1:8701 NEW TRAILS DR STE 150
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77381-4546
Practice Address - Country:US
Practice Address - Phone:281-367-1015
Practice Address - Fax:281-367-1966
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1170902363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health