Provider Demographics
NPI:1184291049
Name:GOTTWALT, TRISTA M (MS, LADC)
Entity type:Individual
Prefix:MS
First Name:TRISTA
Middle Name:M
Last Name:GOTTWALT
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13313 DELORES DR
Mailing Address - Street 2:
Mailing Address - City:PIERZ
Mailing Address - State:MN
Mailing Address - Zip Code:56364-4238
Mailing Address - Country:US
Mailing Address - Phone:320-360-1810
Mailing Address - Fax:
Practice Address - Street 1:2140 NORTHDALE BLVD NW # 220
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3005
Practice Address - Country:US
Practice Address - Phone:763-537-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306045101YA0400X
MN4115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)