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General NPI Number Information
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NPI Number | 1538684725
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Entity Type | Individual
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Provider Name | CASSANDRA MARY NICOTRA
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Gender | Female
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Dates
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Enumeration Date | 08/08/2017
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Last Update Date | 08/12/2024
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Provider Practice Location Address
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Address Line | 3401 CIVIC CENTER BLVD
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4319
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Country | US
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Telephone | 215-590-6267
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Fax |
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Provider Business Mailing Address
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Address Line | 2609 SE 21ST PL
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City | CAPE CORAL
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State | FL
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Zip | 33904-3275
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Country | US
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Telephone | 239-410-5601
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | OS023869
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License Number State | PA
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