Provider Demographics
NPI:1104978998
Name:CASSIDY, STEPHEN EDWIN (PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWIN
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 REDWING ROAD
Mailing Address - Street 2:SUITE 316
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2879
Mailing Address - Country:US
Mailing Address - Phone:970-229-9959
Mailing Address - Fax:970-223-1325
Practice Address - Street 1:2629 REDWING ROAD
Practice Address - Street 2:SUITE 316
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2879
Practice Address - Country:US
Practice Address - Phone:970-229-9959
Practice Address - Fax:970-223-1325
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1049103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical