Provider Demographics
NPI:1083482046
Name:STREET, NASTASIA MARIE
Entity Type:Individual
Prefix:
First Name:NASTASIA
Middle Name:MARIE
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 ASHCROFT CT
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7476
Mailing Address - Country:US
Mailing Address - Phone:720-648-0106
Mailing Address - Fax:
Practice Address - Street 1:402 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3112
Practice Address - Country:US
Practice Address - Phone:910-875-5590
Practice Address - Fax:910-875-5008
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health