Provider Demographics
NPI:1720793649
Name:RICHARDSON, CASSANDRA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 TWIN LAKES TRL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1727
Mailing Address - Country:US
Mailing Address - Phone:770-940-1704
Mailing Address - Fax:
Practice Address - Street 1:1720 MOUNT VERNON RD STE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-4269
Practice Address - Country:US
Practice Address - Phone:678-580-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009116225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist