Provider Demographics
NPI:1376853200
Name:STOCKMAN, KASSIDY KAY (TADC/CPP)
Entity Type:Individual
Prefix:MS
First Name:KASSIDY
Middle Name:KAY
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:TADC/CPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 7TH ST E # 2
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4088
Mailing Address - Country:US
Mailing Address - Phone:612-840-0332
Mailing Address - Fax:
Practice Address - Street 1:1216 7TH ST E # 2
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4088
Practice Address - Country:US
Practice Address - Phone:612-840-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)