Provider Demographics
NPI:1528679743
Name:LIS, CASSIE ANNE (PT, DPT)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:ANNE
Last Name:LIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:ANNE
Other - Last Name:SHARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2411 E RIVERSIDE DR APT Q304
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6855 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8046
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-70212251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics