Basic Information
| Provider Information | |||||||||
| NPI: | 1932626678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISTANICH | ||||||||
| FirstName: | CORINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S. RMHCI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARCIA | ||||||||
| OtherFirstName: | CORINA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 498 SE STARFLOWER AVE | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349834516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15818 SW WARFIELD BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349563513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725970411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2017 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMH15700 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.