Provider Demographics
NPI:1063242832
Name:FASSETT, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:FASSETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MELISSA RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-7437
Mailing Address - Country:US
Mailing Address - Phone:518-636-9900
Mailing Address - Fax:
Practice Address - Street 1:4001 OFFICE COURT DRIVER STE 102
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4903
Practice Address - Country:US
Practice Address - Phone:505-395-9437
Practice Address - Fax:505-930-5427
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health