Provider Demographics
NPI:1497182992
Name:MUNCY, TRISTA (LSW)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:MUNCY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:HOOSIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 ELMWOOD PARK DRIVE SUITE 201
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431
Mailing Address - Country:US
Mailing Address - Phone:937-384-0580
Mailing Address - Fax:
Practice Address - Street 1:100 ELMWOOD PARK DRIVE SUITE 201
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-384-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944294104100000X
OHS.1802082104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker