Provider Demographics
NPI:1588032593
Name:LOLLER, CASSAUNDRA (LCSW)
Entity type:Individual
Prefix:
First Name:CASSAUNDRA
Middle Name:
Last Name:LOLLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7408
Mailing Address - Country:US
Mailing Address - Phone:520-471-5607
Mailing Address - Fax:520-514-2215
Practice Address - Street 1:1120 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7408
Practice Address - Country:US
Practice Address - Phone:520-471-5607
Practice Address - Fax:520-514-2215
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ186311041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program