Healthcare Provider Details

I. General information

NPI: 1558194167
Provider Name (Legal Business Name): TRISTA TRIBBLEGARCIA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRISTA WYSONG

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 ALMIRA DR NE
BREMERTON WA
98311-8331
US

IV. Provider business mailing address

5455 ALMIRA DR NE
BREMERTON WA
98311-8331
US

V. Phone/Fax

Practice location:
  • Phone: 360-373-5031
  • Fax:
Mailing address:
  • Phone: 360-373-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01895
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: