Provider Demographics
NPI:1215482120
Name:WISE, CASSANDRA (PT)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1675 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5501
Practice Address - Country:US
Practice Address - Phone:812-799-1257
Practice Address - Fax:812-799-1258
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012121A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist