Basic Information
| Provider Information | |||||||||
| NPI: | 1811409667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERRSON | ||||||||
| FirstName: | CASANDRA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1175 E MAIN ST STE 1C | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417720127 | ||||||||
| FaxNumber: | 5417720966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2017 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 101Y00000X | 05 | OR | MEDICAID |