Provider Demographics
NPI:1164758769
Name:CASSIDY, CORI
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:
Last Name:CASSIDY
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 1:208 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6044
Mailing Address - Country:US
Mailing Address - Phone:208-342-9225
Mailing Address - Fax:208-342-9260
Practice Address - Street 1:208 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6044
Practice Address - Country:US
Practice Address - Phone:208-342-9225
Practice Address - Fax:208-342-9260
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMX100013173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist