Provider Demographics
NPI:1306309174
Name:REILLEY, CASSANDRA SUSAN (PTA)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:SUSAN
Last Name:REILLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:SUSAN
Other - Last Name:REPAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 S STATE ST
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5907
Practice Address - Country:US
Practice Address - Phone:815-544-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007957225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant