Provider Demographics
NPI:1629101233
Name:CASSIDY, KEVIN M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CROSS OAKS PL
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-6238
Mailing Address - Country:US
Mailing Address - Phone:919-996-9435
Mailing Address - Fax:
Practice Address - Street 1:515 KEISLER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7097
Practice Address - Country:US
Practice Address - Phone:919-996-9435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0055861041C0700X
NY0756411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007428Medicaid