Provider Demographics
NPI:1881456283
Name:GUSTAMA, CASSANDRA (MED, EDS, RMHCI)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:GUSTAMA
Suffix:
Gender:F
Credentials:MED, EDS, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 CRIMSON CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7465
Mailing Address - Country:US
Mailing Address - Phone:407-791-4752
Mailing Address - Fax:
Practice Address - Street 1:1795 STATE RTE 50
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:407-593-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health