Provider Demographics
NPI:1124401534
Name:DIAZ, KASSIDY (DPT)
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KASSIDY
Other - Middle Name:
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:432 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1462
Practice Address - Country:US
Practice Address - Phone:919-258-2714
Practice Address - Fax:410-648-4878
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT026076225000000X
DEJ1-0003367225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEAC44-0066OtherCAREFIRST
DE1124401534Medicaid
DE3288895OtherBS BS DE
DE1124401534Medicaid