Provider Demographics
NPI:1326329582
Name:CASSIDY, DEBRA D (PHD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:D
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 LINCOLN PL
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7037
Mailing Address - Country:US
Mailing Address - Phone:516-319-6928
Mailing Address - Fax:
Practice Address - Street 1:1745 BROADWAY
Practice Address - Street 2:17 FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4640
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019205-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03564692Medicaid
NYA400081990Medicare PIN
NYG4000984510Medicare PIN