Provider Demographics
NPI:1952838666
Name:GILLETTE, MISTY DAWN (BA, CADC)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DAWN
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:MS
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:GRADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 658
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501
Mailing Address - Country:US
Mailing Address - Phone:641-683-6747
Mailing Address - Fax:641-683-6317
Practice Address - Street 1:310 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-683-6747
Practice Address - Fax:641-683-6317
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16187101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)