Provider Demographics
NPI:1184198764
Name:CASSIDY, COLLEEN (M ED)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2528
Mailing Address - Country:US
Mailing Address - Phone:703-346-1836
Mailing Address - Fax:
Practice Address - Street 1:4326 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2528
Practice Address - Country:US
Practice Address - Phone:703-346-1836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA13989252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency