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General NPI Number Information
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NPI Number | 1023615242
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Entity Type | Individual
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Provider Name | CASSIDY FAMULARO MS, LPCC, LADC
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Gender | Female
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Dates
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Enumeration Date | 10/01/2020
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 900 LONG LAKE RD STE 160
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City | NEW BRIGHTON
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State | MN
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Zip | 55112-6414
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Country | US
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Telephone | 612-706-9630
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Fax |
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Provider Business Mailing Address
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Address Line | 7627 10TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55423-4572
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Country | US
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Telephone | 952-217-3291
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 304573
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2527
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License Number State | MN
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