Provider Demographics
NPI:1174184105
Name:MUSGRAVE, MISTI (LMSW, CDCI)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:
Last Name:MUSGRAVE
Suffix:
Gender:F
Credentials:LMSW, CDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N OLD TRUNK RD
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8933
Mailing Address - Country:US
Mailing Address - Phone:907-830-0442
Mailing Address - Fax:
Practice Address - Street 1:5851 E MAYFLOWER CT
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7881
Practice Address - Country:US
Practice Address - Phone:907-357-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1174121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical