Provider Demographics
NPI:1285419895
Name:CASSIDY, CARLY A
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:A
Last Name:CASSIDY
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 1:2180 SQUAK MOUNTAIN LOOP SW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-4416
Mailing Address - Country:US
Mailing Address - Phone:425-829-8132
Mailing Address - Fax:
Practice Address - Street 1:245 E SOUTH BOULDER RD # D326
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2917
Practice Address - Country:US
Practice Address - Phone:425-829-8132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018109101YM0800X
WAMC61477354101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health