MEDICARE: STEPHEN EDWIN CASSIDY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1049	CO

General Provider Information

NPI Number	:	1104978998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN EDWIN CASSIDY PHD

Provider Business Mailing Address
First Line	:	2629 REDWING ROAD
Second Line	:	SUITE 316
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2879
Country	:	US
Telephone Number	:	970-229-9959
Fax Number	:	970-223-1325

Provider Business Practice Location Address
First Line	:	2629 REDWING ROAD
Second Line	:	SUITE 316
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-2879
Country	:	US
Telephone Number	:	970-229-9959
Fax Number	:	970-223-1325

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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