Provider Demographics
NPI:1477197903
Name:CACCAM, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:CACCAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 ROWLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3050
Mailing Address - Country:US
Mailing Address - Phone:805-657-7997
Mailing Address - Fax:
Practice Address - Street 1:14850 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4618
Practice Address - Country:US
Practice Address - Phone:818-904-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95163263163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95136263OtherRN