Provider Demographics
NPI:1861977449
Name:SANDY-BOURNE, KASSIDY
Entity type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:SANDY-BOURNE
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 1:225 BROADHOLLOW RD STE 205
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4822
Mailing Address - Country:US
Mailing Address - Phone:631-385-7780
Mailing Address - Fax:631-385-7795
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:613-385-7795
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker