Provider Demographics
NPI:1821481300
Name:CASSIDY, SHAMUS
Entity Type:Individual
Prefix:
First Name:SHAMUS
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 1:2400 20TH AVE NW
Mailing Address - Street 2:4D
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4178
Mailing Address - Country:US
Mailing Address - Phone:323-440-2977
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST
Practice Address - Street 2:STE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2019-10-18
Deactivation Date:2019-10-03
Deactivation Code:
Reactivation Date:2019-10-17
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
0-19-9497106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician