Provider Demographics
NPI:1063243830
Name:SMITH, CASSIDY ROSE (BA)
Entity type:Individual
Prefix:MISS
First Name:CASSIDY
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4300
Mailing Address - Country:US
Mailing Address - Phone:360-337-4625
Mailing Address - Fax:
Practice Address - Street 1:661 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4300
Practice Address - Country:US
Practice Address - Phone:360-337-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61305813101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)