Healthcare Provider Details

I. General information

NPI: 1235748815
Provider Name (Legal Business Name): MISTY FAST SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

203 UNITED WAY
FREDERIC WI
54837-8938
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4402
  • Fax:
Mailing address:
  • Phone: 715-327-4402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12168-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18954-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: