Healthcare Provider Details

I. General information

NPI: 1205239357
Provider Name (Legal Business Name): CASANDRA MERRITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N MOON AVE
BRANDON FL
33510-4419
US

IV. Provider business mailing address

135 N MOON AVE
BRANDON FL
33510-4419
US

V. Phone/Fax

Practice location:
  • Phone: 813-489-4547
  • Fax: 813-381-5140
Mailing address:
  • Phone: 813-489-4547
  • Fax: 813-381-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCMS100611
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 12768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: