Healthcare Provider Details

I. General information

NPI: 1720758246
Provider Name (Legal Business Name): KASSANDRA MARIE MOWERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7067 TIFFANY BLVD STE 270
YOUNGSTOWN OH
44514-1803
US

IV. Provider business mailing address

7067 TIFFANY BLVD STE 270
YOUNGSTOWN OH
44514-1803
US

V. Phone/Fax

Practice location:
  • Phone: 234-230-1627
  • Fax:
Mailing address:
  • Phone: 234-230-1627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180171
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: