Provider Demographics
NPI:1043020274
Name:MCCALLUM, CASSIDY DANIELLE (SUDPT)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:DANIELLE
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 RUBY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-6103
Mailing Address - Country:US
Mailing Address - Phone:360-952-2430
Mailing Address - Fax:
Practice Address - Street 1:33 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3414
Practice Address - Country:US
Practice Address - Phone:360-952-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61361108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0948131Medicaid