Provider Demographics
NPI:1013499771
Name:COLVIN, CASSANDRA R (RADT-1)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:R
Last Name:COLVIN
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11224 HUNTINGRIDE CIR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4732
Practice Address - Country:US
Practice Address - Phone:619-396-8919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD3960130OtherDRIVER LICENSE