Provider Demographics
NPI:1447509948
Name:KASSEBAUM, MARK A (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KASSEBAUM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:LINN CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65052-1687
Mailing Address - Country:US
Mailing Address - Phone:573-346-6758
Mailing Address - Fax:573-346-0621
Practice Address - Street 1:1091 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:LINN CREEK
Practice Address - State:MO
Practice Address - Zip Code:65052-1687
Practice Address - Country:US
Practice Address - Phone:573-346-6758
Practice Address - Fax:573-346-0621
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007004366101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor