Provider Demographics
NPI:1750816872
Name:BICKERSTAFF, CLINT CHRISTIAN (BA)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:CHRISTIAN
Last Name:BICKERSTAFF
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14410 REUTER STRASSE CIR
Mailing Address - Street 2:#3
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3084
Mailing Address - Country:US
Mailing Address - Phone:303-949-0075
Mailing Address - Fax:
Practice Address - Street 1:14410 REUTER STRASSE CIR
Practice Address - Street 2:#3
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3084
Practice Address - Country:US
Practice Address - Phone:303-949-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL172V00000XMedicaid