Provider Demographics
NPI:1306921903
Name:CASADY, JOHNNY G (LPCC)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:G
Last Name:CASADY
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 S ROOSEVELT ROAD R 1/2
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9015
Mailing Address - Country:US
Mailing Address - Phone:505-760-4103
Mailing Address - Fax:
Practice Address - Street 1:300 EAST 1ST STREET
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:505-359-1221
Practice Address - Fax:505-359-1075
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0080341101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health