Provider Demographics
NPI:1114273232
Name:GOVAN, CASSAUNDRA LINETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CASSAUNDRA
Middle Name:LINETTE
Last Name:GOVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CASSAUNDRA
Other - Middle Name:LINETTE
Other - Last Name:GOVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:5755 BELMONT RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4073
Mailing Address - Country:US
Mailing Address - Phone:678-386-5372
Mailing Address - Fax:
Practice Address - Street 1:5755 BELMONT RIDGE CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-4073
Practice Address - Country:US
Practice Address - Phone:678-386-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004382103T00000X
GALPC006231101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12471700OtherCAQH
GA00313788AMedicaid