=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528102654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE COUNSELING ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 11/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4510 COLLINS BLVD SUITE 2
-----------------------------------------------------
City | ASHTABULA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44004-6954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-992-7878
-----------------------------------------------------
Fax | 440-992-7887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4510 COLLINS BLVD SUITE 2
-----------------------------------------------------
City | ASHTABULA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44004-6954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-992-7878
-----------------------------------------------------
Fax | 440-992-7887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF THE CORPORATION
-----------------------------------------------------
Name | DR. THOMAS M CASSADY
-----------------------------------------------------
Credential | PHD, PSYCHOLOGIST
-----------------------------------------------------
Telephone | 440-992-7878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I0002303
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E2512
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E3468
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E4265
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I217
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I9169
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 34-00-1718-M
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3565
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------