Provider Demographics
NPI:1376924514
Name:JOHNSON, CASSANDRA LATASHA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:LATASHA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 ELLIS ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-1464
Mailing Address - Country:US
Mailing Address - Phone:706-550-0723
Mailing Address - Fax:706-755-2860
Practice Address - Street 1:630 ELLIS ST STE 3A
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1464
Practice Address - Country:US
Practice Address - Phone:706-550-0723
Practice Address - Fax:706-755-2860
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC010321OtherLICENSED PROFESSIONAL COUNSELOR