Provider Demographics
NPI:1720320328
Name:DAVIS, CASSIE
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:DAVIS
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 1:3522 BRIAR CREEK LN
Mailing Address - Street 2:PO BOX 3858
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4728
Mailing Address - Country:US
Mailing Address - Phone:208-529-1660
Mailing Address - Fax:208-529-1699
Practice Address - Street 1:3522 BRIAR CREEK LN
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4728
Practice Address - Country:US
Practice Address - Phone:208-529-1660
Practice Address - Fax:208-529-1699
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-325841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLMSW-32584OtherSTATE LICENSE - LMSW