Healthcare Provider Details

I. General information

NPI: 1972014108
Provider Name (Legal Business Name): NICASIO RENALDO LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

IV. Provider business mailing address

400 N TAMPA ST STE 1550
TAMPA FL
33602-4737
US

V. Phone/Fax

Practice location:
  • Phone: 239-690-6906
  • Fax:
Mailing address:
  • Phone: 727-222-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH27939
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: