Provider Demographics
NPI:1033715735
Name:SKALICKY, CASSIE J
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:J
Last Name:SKALICKY
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 1:4410 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8296
Mailing Address - Country:US
Mailing Address - Phone:701-405-3838
Mailing Address - Fax:
Practice Address - Street 1:505 BROADWAY N STE 206
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4489
Practice Address - Country:US
Practice Address - Phone:701-356-7836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460508Medicaid