Provider Demographics
NPI:1083121420
Name:JOHNSON, KASSANDRA LEE
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:LEE
Last Name:JOHNSON
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 1:2570 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221
Mailing Address - Country:US
Mailing Address - Phone:330-984-8205
Mailing Address - Fax:
Practice Address - Street 1:3740 EUCLID AVE STE 200
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2228
Practice Address - Country:US
Practice Address - Phone:216-361-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LICDC.162035101YA0400X
C.2002863101YM0800X
OHCDCA.162127101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health