Provider Demographics
NPI:1346712270
Name:KNUST, MISSI FA (LCDC)
Entity Type:Individual
Prefix:
First Name:MISSI
Middle Name:FA
Last Name:KNUST
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:MISSI
Other - Middle Name:FAWN ANICE
Other - Last Name:KNUST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCDC
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4300
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-569-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
TX15478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)