Provider Demographics
NPI:1891071148
Name:JOHNSON, CASSANDRA D
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:D
Last Name:JOHNSON
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 1:1310 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-3446
Mailing Address - Country:US
Mailing Address - Phone:580-286-6671
Mailing Address - Fax:580-286-5747
Practice Address - Street 1:1310 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3446
Practice Address - Country:US
Practice Address - Phone:580-286-6671
Practice Address - Fax:580-286-5747
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor