Provider Demographics
NPI:1548566789
Name:KAST, ELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:KAST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-0410
Mailing Address - Country:US
Mailing Address - Phone:727-743-3406
Mailing Address - Fax:
Practice Address - Street 1:1130 PINEHURST RD
Practice Address - Street 2:SUITE D
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5408
Practice Address - Country:US
Practice Address - Phone:727-743-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-06
Last Update Date:2011-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA00017742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist