Provider Demographics
NPI:1942851019
Name:PROVO, CASSIDY DIANE (PPC)
Entity Type:Individual
Prefix:MRS
First Name:CASSIDY
Middle Name:DIANE
Last Name:PROVO
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:MISS
Other - First Name:CASSIDY
Other - Middle Name:DIANE
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2241 FARNUM ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4108
Mailing Address - Country:US
Mailing Address - Phone:307-234-9979
Mailing Address - Fax:307-234-9989
Practice Address - Street 1:2241 FARNUM ST STE 102
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4108
Practice Address - Country:US
Practice Address - Phone:307-234-9979
Practice Address - Fax:307-234-9989
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1151101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1295286185Medicaid