Provider Demographics
NPI:1649839309
Name:RALPH, CASSIDY BROOKE
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:BROOKE
Last Name:RALPH
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 1:2512 S 450 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4313
Mailing Address - Country:US
Mailing Address - Phone:801-971-5848
Mailing Address - Fax:
Practice Address - Street 1:2512 S 450 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4313
Practice Address - Country:US
Practice Address - Phone:801-971-5848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT213227408OtherDRIVER LICENSE NUMBER