Provider Demographics
NPI:1891396255
Name:COATES, CASSANDRA C (SAC-IT)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:C
Last Name:COATES
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MAIN ST APT 117
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-4623
Mailing Address - Country:US
Mailing Address - Phone:262-822-7740
Mailing Address - Fax:
Practice Address - Street 1:134 MAIN ST APT 117
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-4623
Practice Address - Country:US
Practice Address - Phone:262-822-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18959-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)