Provider Demographics
NPI:1225510423
Name:ESTIFAT, CASSI RACQUEL
Entity Type:Individual
Prefix:
First Name:CASSI
Middle Name:RACQUEL
Last Name:ESTIFAT
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 1:1402 REYNOLDS CT
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-2877
Mailing Address - Country:US
Mailing Address - Phone:772-985-4929
Mailing Address - Fax:
Practice Address - Street 1:1402 REYNOLDS CT
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-2877
Practice Address - Country:US
Practice Address - Phone:772-985-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL255093101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82-4610285Medicaid
FL$$$$$$$$$Medicaid