Provider Demographics
NPI:1114350592
Name:CASSIDY, PATRICK KYLE (PSYCH TECH)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:KYLE
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:PSYCH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 EMAN CT
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3222
Mailing Address - Country:US
Mailing Address - Phone:928-542-9079
Mailing Address - Fax:
Practice Address - Street 1:640 EMAN CT
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3222
Practice Address - Country:US
Practice Address - Phone:928-542-9079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36895167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician