Healthcare Provider Details

I. General information

NPI: 1588729990
Provider Name (Legal Business Name): TRISTRAM HEYWARD DASHTI-GIBSON LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 ISLINGTON ST STE 4
PORTSMOUTH NH
03801-4471
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 603-689-7890
  • Fax: 603-883-0007
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC3922
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number993
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: