Provider Demographics
NPI:1285341941
Name:ICENHOUR, CASSIDY LEIGH
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:LEIGH
Last Name:ICENHOUR
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 1:248 TRIPLE CROWN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-8023
Mailing Address - Country:US
Mailing Address - Phone:501-744-9594
Mailing Address - Fax:
Practice Address - Street 1:400 N ERIE HWY STE A
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-4264
Practice Address - Country:US
Practice Address - Phone:513-887-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT012243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOT012243Medicaid