Provider Demographics
NPI:1487995585
Name:GRAY, CASSONDRA
Entity type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:
Last Name:GRAY
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 1:3055 OAKCREST DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-2587
Mailing Address - Country:US
Mailing Address - Phone:409-356-3842
Mailing Address - Fax:
Practice Address - Street 1:8706 JEFFERSON HWY STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2233
Practice Address - Country:US
Practice Address - Phone:225-926-9706
Practice Address - Fax:225-926-9708
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9945171M00000X, 101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health