Provider Demographics
NPI:1558718320
Name:ELLEDGE, CASSANDRA LYNN (LPC, SDP-A)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LYNN
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:LPC, SDP-A
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 2833
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-2833
Mailing Address - Country:US
Mailing Address - Phone:870-754-6777
Mailing Address - Fax:
Practice Address - Street 1:303 N MAIN ST STE 104B
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3508
Practice Address - Country:US
Practice Address - Phone:870-754-6777
Practice Address - Fax:877-891-2461
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator