Provider Demographics
NPI:1760919633
Name:CASSIDY, BRIAN (LPC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 GROSS DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2056
Mailing Address - Country:US
Mailing Address - Phone:479-856-2767
Mailing Address - Fax:
Practice Address - Street 1:4000 SAN ERNESTO AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2874
Practice Address - Country:US
Practice Address - Phone:907-729-5055
Practice Address - Fax:907-729-5055
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK120740101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional