Provider Demographics
NPI:1245900638
Name:PESATURO, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PESATURO
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 1:686 BOUNDARY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROTONDA WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33947-2036
Mailing Address - Country:US
Mailing Address - Phone:904-805-2898
Mailing Address - Fax:
Practice Address - Street 1:4161 TAMIAMI TRL STE 601
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9283
Practice Address - Country:US
Practice Address - Phone:941-235-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker