Provider Demographics
NPI:1942802806
Name:RAISTRICK, EMILIE N (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:N
Last Name:RAISTRICK
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 1:50 LEANNI WAY UNIT C4
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4755
Mailing Address - Country:US
Mailing Address - Phone:386-627-8156
Mailing Address - Fax:
Practice Address - Street 1:30 HOULTON ST
Practice Address - Street 2:
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765-3035
Practice Address - Country:US
Practice Address - Phone:866-366-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-14
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW177491041C0700X
MELC211141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical