Provider Demographics
NPI:1659835619
Name:SMITH, CASSIDY (CT)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:495 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5349
Practice Address - Country:US
Practice Address - Phone:614-355-8055
Practice Address - Fax:614-355-8056
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid