Provider Demographics
NPI:1568113538
Name:CASSIDY, KELLIE-MARIE
Entity Type:Individual
Prefix:
First Name:KELLIE-MARIE
Middle Name:
Last Name:CASSIDY
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 1:443 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2212
Mailing Address - Country:US
Mailing Address - Phone:516-712-4665
Mailing Address - Fax:
Practice Address - Street 1:443 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2212
Practice Address - Country:US
Practice Address - Phone:516-712-4665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator