Provider Demographics
NPI:1447617592
Name:DETTWILLER, CASSANDRA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:CASSANDRA
Middle Name:
Last Name:DETTWILLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 SNAKE RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45123-9593
Mailing Address - Country:US
Mailing Address - Phone:937-661-4919
Mailing Address - Fax:
Practice Address - Street 1:850 NELLIE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-1567
Practice Address - Country:US
Practice Address - Phone:937-981-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04249314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility