Healthcare Provider Details

I. General information

NPI: 1023830247
Provider Name (Legal Business Name): CASSANDRA CASTANEDA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W JANSSEN AVE
DE QUEEN AR
71832-2235
US

IV. Provider business mailing address

902 W JANSSEN AVE
DE QUEEN AR
71832-2235
US

V. Phone/Fax

Practice location:
  • Phone: 870-279-3566
  • Fax: 870-279-3566
Mailing address:
  • Phone: 870-279-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2409002
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: