Basic Information
| Provider Information | |||||||||
| NPI: | 1952315269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISTEL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | RENA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPYAN | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | RENA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 72 | MA | Y | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | AUD00112 | RI | N | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | AD0149 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 5102154 | 05 | MA | MEDICAID | 29016-4/411655 | 01 | RI | BLUE CROSS BLUE SHIELD | OTHER |