Provider Demographics
NPI:1093442014
Name:ROE, KASSIDY LYN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:LYN
Last Name:ROE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 ALFORD RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9725
Mailing Address - Country:US
Mailing Address - Phone:734-497-7165
Mailing Address - Fax:
Practice Address - Street 1:200 SAND CREEK HWY
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1255
Practice Address - Country:US
Practice Address - Phone:517-263-6794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013038225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861488108Medicaid