Provider Demographics
NPI:1710740519
Name:CASSIDY, CRAIG
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 NOWITA PL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3519
Mailing Address - Country:US
Mailing Address - Phone:310-569-6745
Mailing Address - Fax:
Practice Address - Street 1:1022 NOWITA PL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3519
Practice Address - Country:US
Practice Address - Phone:310-569-6745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health