Healthcare Provider Details

I. General information

NPI: 1629101233
Provider Name (Legal Business Name): KEVIN M. CASSIDY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 KEISLER DR SUITE 104
CARY NC
27518-7097
US

IV. Provider business mailing address

209 CROSS OAKS PL
HOLLY SPRINGS NC
27540-6238
US

V. Phone/Fax

Practice location:
  • Phone: 919-996-9435
  • Fax:
Mailing address:
  • Phone: 919-996-9435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005586
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075641
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6007428
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: