Provider Demographics
NPI:1275960049
Name:CASSMAN, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:CASSMAN
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 1:12527 CENTRAL AVE NE # 146
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4861
Mailing Address - Country:US
Mailing Address - Phone:218-252-0233
Mailing Address - Fax:
Practice Address - Street 1:12527 CENTRAL AVE NE # 146
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4861
Practice Address - Country:US
Practice Address - Phone:218-252-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103K0000X101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral