Provider Demographics
NPI:1457622896
Name:FENTON, MISTY LEE (MED, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:LEE
Last Name:FENTON
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 W SAN MIGUEL ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5949
Mailing Address - Country:US
Mailing Address - Phone:850-585-7735
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:SUITE 326
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2288
Practice Address - Country:US
Practice Address - Phone:813-400-3344
Practice Address - Fax:813-288-6907
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health