Healthcare Provider Details

I. General information

NPI: 1174184105
Provider Name (Legal Business Name): MISTI MUSGRAVE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 874861
WASILLA AK
99687-4861
US

IV. Provider business mailing address

PO BOX 874861
WASILLA AK
99687-4861
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-6200
  • Fax:
Mailing address:
  • Phone: 907-373-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number148301
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: