Healthcare Provider Details

I. General information

NPI: 1174040356
Provider Name (Legal Business Name): CASSIDY ANN STRADLING CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CAMINO ESPANOL NW
ALBUQUERQUE NM
87107-5817
US

IV. Provider business mailing address

659 CHUCKWAGON RD SE
RIO RANCHO NM
87124-3712
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-5204
  • Fax:
Mailing address:
  • Phone: 505-306-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP7321
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: