Provider Demographics
NPI:1407929102
Name:CASSIDY, SALLY A (LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 WESTWOOD BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4954
Mailing Address - Country:US
Mailing Address - Phone:310-266-1795
Mailing Address - Fax:
Practice Address - Street 1:1416 WESTWOOD BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4954
Practice Address - Country:US
Practice Address - Phone:310-266-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS178681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW17868AMedicare ID - Type Unspecified