Healthcare Provider Details

I. General information

NPI: 1013418557
Provider Name (Legal Business Name): CASSIDY ELM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 LEWIS AVE
MERIDEN CT
06451-2101
US

IV. Provider business mailing address

1376 OLD WATERBURY RD
SOUTHBURY CT
06488-1910
US

V. Phone/Fax

Practice location:
  • Phone: 203-694-8200
  • Fax:
Mailing address:
  • Phone: 203-264-8939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number185458
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: