Healthcare Provider Details

I. General information

NPI: 1013523661
Provider Name (Legal Business Name): CASSIDY BINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 GREEN ST
JAMAICA PLAIN MA
02130-2667
US

IV. Provider business mailing address

20B MOUNT VERNON ST
BRIGHTON MA
02135
US

V. Phone/Fax

Practice location:
  • Phone: 617-524-1120
  • Fax:
Mailing address:
  • Phone: 727-410-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: