Provider Demographics
NPI:1730472200
Name:WOODSON, CASSIE
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:WOODSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34404 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:OK
Mailing Address - Zip Code:74577-1020
Mailing Address - Country:US
Mailing Address - Phone:580-980-1527
Mailing Address - Fax:
Practice Address - Street 1:34404 RIVER RD
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:OK
Practice Address - Zip Code:74577-1020
Practice Address - Country:US
Practice Address - Phone:580-980-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2015-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional