Provider Demographics
NPI:1982152278
Name:TASTET-ORTIZ, KAIDI (LCSW)
Entity Type:Individual
Prefix:
First Name:KAIDI
Middle Name:
Last Name:TASTET-ORTIZ
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 1:1400 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4190
Mailing Address - Country:US
Mailing Address - Phone:904-829-2273
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4190
Practice Address - Country:US
Practice Address - Phone:904-829-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW122221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical