=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831854652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA DELIA UNDERWOOD LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2021
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11900 BLUE SPRUCE CT
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-214-6430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11900 BLUE SPRUCE CT
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 23891
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------