Provider Demographics
NPI:1194207118
Name:GONZALES, CASSIE (QBHP)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 HALBERT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2607
Mailing Address - Country:US
Mailing Address - Phone:501-332-4400
Mailing Address - Fax:501-332-4403
Practice Address - Street 1:1401 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801
Practice Address - Country:US
Practice Address - Phone:870-777-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227291795Medicaid