Provider Demographics
NPI:1073844544
Name:RICHARDSON, CASSANDRA LYNN
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:LYNN
Last Name:RICHARDSON
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 1:13034 CHAMPAIGN AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1348
Mailing Address - Country:US
Mailing Address - Phone:586-944-3798
Mailing Address - Fax:586-757-8386
Practice Address - Street 1:17200 W 10 MILE RD
Practice Address - Street 2:SUITE 113
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2928
Practice Address - Country:US
Practice Address - Phone:248-443-1940
Practice Address - Fax:586-757-8386
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-23
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6401011793101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI630255OtherCATHOLIC SOCIAL SERVICES OF OAKLAND COUNTY