Provider Demographics
NPI:1518410109
Name:CASSIDY, MICHAEL CHARLES (MA, LAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 THIRD AVE
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:MT
Mailing Address - Zip Code:59875-2357
Mailing Address - Country:US
Mailing Address - Phone:406-241-9849
Mailing Address - Fax:406-363-3061
Practice Address - Street 1:330 THIRD AVE
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:MT
Practice Address - Zip Code:59875-2357
Practice Address - Country:US
Practice Address - Phone:406-241-9849
Practice Address - Fax:406-363-3061
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-18797101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)