Provider Demographics
NPI:1174025084
Name:FISHER, KASSANDRA ESTELLE
Entity Type:Individual
Prefix:MRS
First Name:KASSANDRA
Middle Name:ESTELLE
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28807 BESTE ST.
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225X00000X
MI5201009486225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist