Provider Demographics
NPI:1063917920
Name:CASSIDY, KIMBERLY KEMP
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KEMP
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 BRADFORD PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-8189
Mailing Address - Country:US
Mailing Address - Phone:919-396-2833
Mailing Address - Fax:
Practice Address - Street 1:2502 BRADFORD PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-8189
Practice Address - Country:US
Practice Address - Phone:919-396-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency