Provider Demographics
NPI:1538684725
Name:NICOTRA, CASSANDRA MARY
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARY
Last Name:NICOTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 SE 21ST PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-3275
Mailing Address - Country:US
Mailing Address - Phone:239-410-5601
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2024-08-12
Deactivation Date:2018-05-02
Deactivation Code:
Reactivation Date:2018-08-06
Provider Licenses
StateLicense IDTaxonomies
PAOS0238692084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry