Provider Demographics
NPI:1508382219
Name:GORMAN, CASSIDY
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:GORMAN
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 1:211 E STADIUM
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2032
Mailing Address - Country:US
Mailing Address - Phone:870-234-7604
Mailing Address - Fax:
Practice Address - Street 1:211 E STADIUM
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2032
Practice Address - Country:US
Practice Address - Phone:870-234-7604
Practice Address - Fax:870-234-7604
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4238225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant