Provider Demographics
NPI:1427377647
Name:MCKASSON, ROBERT EDWARD JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:MCKASSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92693-0130
Mailing Address - Country:US
Mailing Address - Phone:949-458-2715
Mailing Address - Fax:
Practice Address - Street 1:22471 ASPAN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1642
Practice Address - Country:US
Practice Address - Phone:949-458-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor