Provider Demographics
NPI:1720243306
Name:BENNETT, CASSANDRA (MS, CAGS)
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS, CAGS
Other - Prefix:MISS
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1460 N PINAL AVE
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-3337
Mailing Address - Country:US
Mailing Address - Phone:520-836-2111
Mailing Address - Fax:520-876-3646
Practice Address - Street 1:2172 N ARIZOLA RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-6372
Practice Address - Country:US
Practice Address - Phone:520-876-5397
Practice Address - Fax:520-876-0909
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3546284103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool