Provider Demographics
NPI:1689791089
Name:MOUNTCASTLE, JODY E (LCSW)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:E
Last Name:MOUNTCASTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-9116
Mailing Address - Country:US
Mailing Address - Phone:941-363-0878
Mailing Address - Fax:941-460-5599
Practice Address - Street 1:304 S 22ND ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501-4726
Practice Address - Country:US
Practice Address - Phone:254-298-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLC164141041C0700X
MELC164141041C0700X
TX1054881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431811599Medicaid