Provider Demographics
NPI:1871074146
Name:MOFFETT, TRISTA SHARI (LCSW)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:SHARI
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2514
Mailing Address - Country:US
Mailing Address - Phone:850-778-9110
Mailing Address - Fax:850-399-9663
Practice Address - Street 1:502 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2514
Practice Address - Country:US
Practice Address - Phone:850-778-9110
Practice Address - Fax:850-399-9663
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW151121041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical