Provider Demographics
NPI:1205569720
Name:CASSIDY, THOMAS ALLEN
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALLEN
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-1267
Mailing Address - Country:US
Mailing Address - Phone:707-235-7503
Mailing Address - Fax:
Practice Address - Street 1:2403 PROFESSIONAL DR STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3007
Practice Address - Country:US
Practice Address - Phone:707-544-3295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143721106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist