Provider Demographics
NPI:1245576172
Name:LOPEZ, KASANDRA LEANNE
Entity type:Individual
Prefix:MS
First Name:KASANDRA
Middle Name:LEANNE
Last Name:LOPEZ
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 1:550 SE MAYBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1866
Mailing Address - Country:US
Mailing Address - Phone:541-224-3560
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9695
Practice Address - Country:US
Practice Address - Phone:541-758-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health