Provider Demographics
NPI:1124216064
Name:BLUNDY, CASSIDY LEE (PTA)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:LEE
Last Name:BLUNDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 LEMAY FERRY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1576
Mailing Address - Country:US
Mailing Address - Phone:314-416-0439
Mailing Address - Fax:314-487-3062
Practice Address - Street 1:3431 BRIDGELAND DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2604
Practice Address - Country:US
Practice Address - Phone:314-373-2095
Practice Address - Fax:314-373-2096
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007028760225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant