Healthcare Provider Details

I. General information

NPI: 1275960049
Provider Name (Legal Business Name): MRS. LISA CASSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12527 CENTRAL AVE NE # 146
BLAINE MN
55434-4861
US

IV. Provider business mailing address

12527 CENTRAL AVE NE # 146
BLAINE MN
55434-4861
US

V. Phone/Fax

Practice location:
  • Phone: 218-252-0233
  • Fax:
Mailing address:
  • Phone: 218-252-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number103K0000X
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: