Provider Demographics
NPI:1518612845
Name:OITKER, CASSIDY ROSE
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:ROSE
Last Name:OITKER
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 1:3048 S CLIFTON AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-6045
Mailing Address - Country:US
Mailing Address - Phone:417-830-2338
Mailing Address - Fax:
Practice Address - Street 1:3048 S CLIFTON AVE STE 112
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6045
Practice Address - Country:US
Practice Address - Phone:417-818-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-21-170628103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst