=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013382050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIDEE UTTERBACK BCBA, M.ED.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2015
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1395 N MCEWAN ST
-----------------------------------------------------
City | CLARE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48617-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-423-5346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4260 N ALAMANDO RD
-----------------------------------------------------
City | COLEMAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48618-9541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-322-4150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 7401001050
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------