Provider Demographics
NPI:1942616883
Name:CASEY, CLYDE
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:CASEY
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 1:1401 UNIVERSITY BLVD E
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-4029
Mailing Address - Country:US
Mailing Address - Phone:301-434-4890
Mailing Address - Fax:301-434-4896
Practice Address - Street 1:1401 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-4029
Practice Address - Country:US
Practice Address - Phone:301-434-4890
Practice Address - Fax:301-434-4896
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA434101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)