Provider Demographics
NPI:1437532058
Name:DAVID, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:DAVID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BROOKSIDE AVE UNIT 244
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-2510
Mailing Address - Country:US
Mailing Address - Phone:951-755-1070
Mailing Address - Fax:
Practice Address - Street 1:473 S CARNEGIE DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4201
Practice Address - Country:US
Practice Address - Phone:951-755-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA886581041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health