Provider Demographics
NPI:1114425725
Name:QUEDNAU, KASANDRA
Entity Type:Individual
Prefix:
First Name:KASANDRA
Middle Name:
Last Name:QUEDNAU
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 1:142 RUDY FRANK RD EXT
Mailing Address - Street 2:PO BOX 141
Mailing Address - City:SHANDAKEN
Mailing Address - State:NY
Mailing Address - Zip Code:12480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:396 BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1157
Practice Address - Country:US
Practice Address - Phone:845-544-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)