Healthcare Provider Details

I. General information

NPI: 1619081981
Provider Name (Legal Business Name): COLLEEN MARIE CASSIDY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E LA PALMA AVE SUITE 101
ANAHEIM CA
92805-1647
US

IV. Provider business mailing address

16661 DOLORES ST APT B
HUNTINGTON BEACH CA
92649-3341
US

V. Phone/Fax

Practice location:
  • Phone: 714-399-3480
  • Fax:
Mailing address:
  • Phone: 714-840-7301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS19167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: