Healthcare Provider Details

I. General information

NPI: 1255812624
Provider Name (Legal Business Name): MISTY TABISULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7370 IVEY HILL CIR
HAHIRA GA
31632-2275
US

IV. Provider business mailing address

7370 IVEY HILL CIR
HAHIRA GA
31632-2275
US

V. Phone/Fax

Practice location:
  • Phone: 850-973-0285
  • Fax:
Mailing address:
  • Phone: 850-973-0285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCCMH0201901
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0197861
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001348
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008435
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: