Provider Demographics
NPI:1639257801
Name:ROBERSON, CASSANDRA KAY (LAC)
Entity Type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:KAY
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4533 LOUISIANA AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-5026
Mailing Address - Country:US
Mailing Address - Phone:763-536-9350
Mailing Address - Fax:
Practice Address - Street 1:2817 LYNDALE AVE S STE E
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2152
Practice Address - Country:US
Practice Address - Phone:763-536-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1136171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist