Provider Demographics
NPI:1124295811
Name:CASSIDY, KRISTINA (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7624
Mailing Address - Country:US
Mailing Address - Phone:614-501-9983
Mailing Address - Fax:
Practice Address - Street 1:1230 RESERVE DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7624
Practice Address - Country:US
Practice Address - Phone:614-501-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02978224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant