Healthcare Provider Details

I. General information

NPI: 1871074146
Provider Name (Legal Business Name): TRISTA SHARI MOFFETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E 2ND AVE
CRESTVIEW FL
32536-2514
US

IV. Provider business mailing address

502 E 2ND AVE
CRESTVIEW FL
32536-2514
US

V. Phone/Fax

Practice location:
  • Phone: 850-778-9110
  • Fax: 850-399-9663
Mailing address:
  • Phone: 850-778-9110
  • Fax: 850-399-9663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW15112
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW15112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: