Provider Demographics
NPI:1962392191
Name:DAVIS, CASSIDY
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:DAVIS
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 1:377 W WILBUR ST
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-3211
Mailing Address - Country:US
Mailing Address - Phone:240-441-4196
Mailing Address - Fax:
Practice Address - Street 1:87009 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3400
Practice Address - Country:US
Practice Address - Phone:305-807-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-25-439976106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician