Provider Demographics
NPI:1013525401
Name:DEFEO, CASSANDRA (RD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:DEFEO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FOREST AVE APT A
Mailing Address - Street 2:
Mailing Address - City:JEKYLL ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31527-0786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 FOREST AVE APT A
Practice Address - Street 2:
Practice Address - City:JEKYLL ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31527-0786
Practice Address - Country:US
Practice Address - Phone:912-515-5822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007019101YP2500X
GALD004284133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered