Provider Demographics
NPI:1689981334
Name:CASSIDY, NICOLE (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 RICKER RD
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-4263
Mailing Address - Country:US
Mailing Address - Phone:314-935-6666
Mailing Address - Fax:314-935-8515
Practice Address - Street 1:1 BROOKINGS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4862
Practice Address - Country:US
Practice Address - Phone:314-935-6666
Practice Address - Fax:314-935-8515
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical