Provider Demographics
NPI:1588165807
Name:FORT, CASSIE (ATR, LPC)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:ATR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4532 POINSETTIA ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-9500
Mailing Address - Country:US
Mailing Address - Phone:509-595-0944
Mailing Address - Fax:
Practice Address - Street 1:4532 POINSETTIA ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-9500
Practice Address - Country:US
Practice Address - Phone:509-595-0944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4698101YP2500X
OR12-122221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional