Provider Demographics
NPI:1720758246
Name:MOWERY, KASSANDRA MARIE
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:MARIE
Last Name:MOWERY
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 1:7067 TIFFANY BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1803
Mailing Address - Country:US
Mailing Address - Phone:234-230-1627
Mailing Address - Fax:
Practice Address - Street 1:7067 TIFFANY BLVD STE 270
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-1803
Practice Address - Country:US
Practice Address - Phone:234-230-1627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHCDCA.180171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist