Healthcare Provider Details

I. General information

NPI: 1881456283
Provider Name (Legal Business Name): CASSANDRA GUSTAMA M.ED., ED.S., RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 01/30/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 STATE RTE 50
CLERMONT FL
34711
US

IV. Provider business mailing address

3899 CRIMSON CLOVER DR
MOUNT DORA FL
32757-7465
US

V. Phone/Fax

Practice location:
  • Phone: 407-593-4500
  • Fax:
Mailing address:
  • Phone: 407-791-4752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25318
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: