Provider Demographics
NPI:1508298043
Name:CASSIDY, TRACI L (PT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:DELGADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3602 E SUNSET RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-7230
Mailing Address - Country:US
Mailing Address - Phone:702-932-4308
Mailing Address - Fax:702-837-8930
Practice Address - Street 1:3602 E SUNSET RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-7230
Practice Address - Country:US
Practice Address - Phone:702-932-4308
Practice Address - Fax:702-837-8930
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV107550Medicare UPIN