Provider Demographics
NPI:1871206904
Name:GIST, BIANCA
Entity type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:
Last Name:GIST
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 1:6907 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63133-1507
Mailing Address - Country:US
Mailing Address - Phone:636-800-2401
Mailing Address - Fax:
Practice Address - Street 1:6907 PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1507
Practice Address - Country:US
Practice Address - Phone:636-800-2401
Practice Address - Fax:636-800-2402
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RM2200X
MO246RP1900X
MO18571101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy