Provider Demographics
NPI:1255992236
Name:CAUDILL, CASSANDRA GAYLE (LPCC)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:GAYLE
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:GAYLE
Other - Last Name:ROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 MEDPARK SQUARE DR STE 2&3
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1709
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY271277101YA0400X
KY284257101YP2500X
KY265991101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100762610Medicaid