MEDICARE: CASSADY COCO

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	106S00000X	Behavior Technician	RBT-17-37190	MS
2	103K00000X	Behavior Analyst	190069	MS

General Provider Information

NPI Number	:	1114443579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSADY COCO

Provider Business Mailing Address
First Line	:	18 POPLAR DR
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-9547
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 MILLBRANCH RD STE 40
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1673
Country	:	US
Telephone Number	:	601-255-5264
Fax Number	:

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

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	02/13/2019

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Directions to “ CASSADY COCO ” Practice Location

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