Provider Demographics
NPI:1013382050
Name:UTTERBACK, CASSIDEE (BCBA, MED)
Entity Type:Individual
Prefix:
First Name:CASSIDEE
Middle Name:
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:BCBA, MED
Other - Prefix:
Other - First Name:CASSIDEE
Other - Middle Name:JEAN
Other - Last Name:RETZLOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6592 E GOGOMAIN RD
Mailing Address - Street 2:
Mailing Address - City:PICKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49774-9064
Mailing Address - Country:US
Mailing Address - Phone:906-203-7918
Mailing Address - Fax:
Practice Address - Street 1:2650 I 75 BUSINESS SPUR
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3536
Practice Address - Country:US
Practice Address - Phone:906-259-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI7401001050103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other