Provider Demographics
NPI:1992467062
Name:ROBERTSON, KASSIDY ANNE
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:ANNE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:
Practice Address - Street 1:928 12TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4024
Practice Address - Country:US
Practice Address - Phone:970-347-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CO376K00000X
CO0002368101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's Aide