Basic Information
| Provider Information | |||||||||
| NPI: | 1467750653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUFFMAN | ||||||||
| FirstName: | CASSIDY | ||||||||
| MiddleName: | RUTH | ||||||||
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| OtherLastName: | HUFFMAN | ||||||||
| OtherFirstName: | CASSIE | ||||||||
| OtherMiddleName: | RUTH | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 03/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0174571 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 23736071 | 05 | NM | MEDICAID |