Provider Demographics
NPI:1467750653
Name:HUFFMAN, CASSIDY RUTH
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:RUTH
Last Name:HUFFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:RUTH
Other - Last Name:HUFFMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:575-472-4313
Practice Address - Street 1:117 CAMINO DE VIDA
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:575-472-4313
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0174571101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23736071Medicaid