Healthcare Provider Details

I. General information

NPI: 1578223848
Provider Name (Legal Business Name): JOANNE EILEEN CASSERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 E RIO GRANDE ST
PASADENA CA
91104-5044
US

IV. Provider business mailing address

PO BOX 40494
PASADENA CA
91114-7494
US

V. Phone/Fax

Practice location:
  • Phone: 323-528-9856
  • Fax:
Mailing address:
  • Phone: 323-528-9856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW20601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: