Provider Demographics
NPI:1275029357
Name:HENRIQUES, CASSIDY
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:HENRIQUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N 7TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-2414
Mailing Address - Country:US
Mailing Address - Phone:763-412-5463
Mailing Address - Fax:
Practice Address - Street 1:101 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2086
Practice Address - Country:US
Practice Address - Phone:218-724-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician