Provider Demographics
NPI:1700574589
Name:STIDHAM, CASSANDRA KAY (CSW)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:KAY
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:BULAN
Mailing Address - State:KY
Mailing Address - Zip Code:41722-0442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BULLDOG LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-6081
Practice Address - Country:US
Practice Address - Phone:859-436-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2575901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical