Provider Demographics
NPI:1972070266
Name:MCCOWN, KASANDRA MARIE
Entity type:Individual
Prefix:
First Name:KASANDRA
Middle Name:MARIE
Last Name:MCCOWN
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 1:4812 220TH ST E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-6014
Mailing Address - Country:US
Mailing Address - Phone:253-209-0821
Mailing Address - Fax:
Practice Address - Street 1:8308 35TH ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-2004
Practice Address - Country:US
Practice Address - Phone:253-209-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61246957106H00000X
WACG60889012171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1669663712Medicaid