Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | CA |
NPI | 1003199944 |
---|---|
Provider Name | David Cassidy |
First Address | Port Hueneme, CA 93041-3003 |
Second Address | Camarillo, CA 93012-8520 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2011 |
Last Update Date | 27/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
174400000X | OTHER (01) | CA |