Provider Demographics
NPI:1649745779
Name:FORDHAM, CASEY ROSE (BA)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ROSE
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4905
Mailing Address - Country:US
Mailing Address - Phone:516-765-6388
Mailing Address - Fax:
Practice Address - Street 1:75 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4905
Practice Address - Country:US
Practice Address - Phone:516-799-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0958571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical