Provider Demographics
NPI:1487790218
Name:JOHANSON, CASSANDRA
Entity type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 E MURIEL DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9257
Mailing Address - Country:US
Mailing Address - Phone:602-561-8079
Mailing Address - Fax:
Practice Address - Street 1:20402 N, 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027
Practice Address - Country:US
Practice Address - Phone:623-445-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL2188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist