Provider Demographics
NPI:1306361456
Name:CHANNELL, CASSANDRA D (LICDC-CS, LPCC-S)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:D
Last Name:CHANNELL
Suffix:
Gender:F
Credentials:LICDC-CS, LPCC-S
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:CHANNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4369 E KITRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1719
Mailing Address - Country:US
Mailing Address - Phone:937-580-6400
Mailing Address - Fax:
Practice Address - Street 1:4369 E KITRIDGE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-1719
Practice Address - Country:US
Practice Address - Phone:937-580-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161530101YA0400X
OHE.1901557101YM0800X
OHCDCA.160460101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor