Healthcare Provider Details

I. General information

NPI: 1114063187
Provider Name (Legal Business Name): MISTI D ANDERSON MS, CAP, CMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N. FERDON BLVD. B
CRESTVIEW FL
32536
US

IV. Provider business mailing address

207 WESTVIEW DR
CRESTVIEW FL
32536-9254
US

V. Phone/Fax

Practice location:
  • Phone: 850-758-0706
  • Fax:
Mailing address:
  • Phone: 850-689-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3431
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number50228
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: