Provider Demographics
NPI:1619650199
Name:FREDERICK, KASANDRA LEEANN (ACSW, PPSC)
Entity Type:Individual
Prefix:
First Name:KASANDRA
Middle Name:LEEANN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:ACSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-4657
Mailing Address - Country:US
Mailing Address - Phone:559-786-6860
Mailing Address - Fax:
Practice Address - Street 1:197 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-4657
Practice Address - Country:US
Practice Address - Phone:559-786-6860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1100571041C0700X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical