Provider Demographics
NPI:1114493731
Name:SMITH, CASSIDY ANNE (CO60751979)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CO60751979
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SUPERIOR LN
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1623
Mailing Address - Country:US
Mailing Address - Phone:509-853-4172
Mailing Address - Fax:
Practice Address - Street 1:613 SUPERIOR LN
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1623
Practice Address - Country:US
Practice Address - Phone:509-853-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60751979101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)