Provider Demographics
NPI:1124787809
Name:KRIDELBAUGH, CASSANDRA (LCSW)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:KRIDELBAUGH
Suffix:
Gender:F
Credentials:LCSW
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 220122
Mailing Address - Street 2:
Mailing Address - City:CENTERFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84622-0122
Mailing Address - Country:US
Mailing Address - Phone:801-898-7917
Mailing Address - Fax:
Practice Address - Street 1:250 W 100 S
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-8463
Practice Address - Country:US
Practice Address - Phone:801-898-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7133296-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical