Provider Demographics
NPI:1609320993
Name:DAVIS, CASSONDRA
Entity Type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSONDRA
Other - Middle Name:
Other - Last Name:SAN MIGUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9703
Mailing Address - Country:US
Mailing Address - Phone:315-519-5828
Mailing Address - Fax:
Practice Address - Street 1:1001 WEST ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-9703
Practice Address - Country:US
Practice Address - Phone:315-519-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY101097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program