Provider Demographics
NPI:1386936094
Name:DIETZ, CASSANDRA MARIE (OTR)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARIE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:MARIE
Other - Last Name:POLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:164 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1139
Mailing Address - Country:US
Mailing Address - Phone:616-262-1222
Mailing Address - Fax:
Practice Address - Street 1:164 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1139
Practice Address - Country:US
Practice Address - Phone:616-262-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist