Provider Demographics
NPI:1558955401
Name:CASEY, LAQUADA
Entity Type:Individual
Prefix:
First Name:LAQUADA
Middle Name:
Last Name:CASEY
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 1:3851 CAVANAUGH RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2143
Mailing Address - Country:US
Mailing Address - Phone:937-558-6062
Mailing Address - Fax:
Practice Address - Street 1:3851 CAVANAUGH RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-2143
Practice Address - Country:US
Practice Address - Phone:937-558-6062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0451687Medicaid