Provider Demographics
NPI:1447761275
Name:YARBROUGH, KASSANDRA KATHLEEN
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:KATHLEEN
Last Name:YARBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:MOORE-MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2895
Mailing Address - Country:US
Mailing Address - Phone:765-446-6573
Mailing Address - Fax:
Practice Address - Street 1:415 N 26TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2895
Practice Address - Country:US
Practice Address - Phone:765-446-6573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN20043497A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor