Provider Demographics
NPI:1508856857
Name:CASSIDY, MARY ALICE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-3123
Mailing Address - Country:US
Mailing Address - Phone:603-668-3711
Mailing Address - Fax:
Practice Address - Street 1:7 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3921
Practice Address - Country:US
Practice Address - Phone:603-889-6147
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH14Y001177NH01OtherANTHEM BLUE CROSS B S
NH81263591Medicaid
NH14Y001177NH01OtherANTHEM BLUE CROSS B S