Healthcare Provider Details

I. General information

NPI: 1265097950
Provider Name (Legal Business Name): CASANDRA COSSEY LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CULEBRA RD.
SAN ANTONIO TX
78228
US

IV. Provider business mailing address

700 S. ZARZAMORA STE 209
SAN ANTONIO TX
78207
US

V. Phone/Fax

Practice location:
  • Phone: 210-314-6473
  • Fax: 210-314-8676
Mailing address:
  • Phone: 210-822-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16102
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: