Provider Demographics
NPI:1598089518
Name:DIAZ CASSIDY, IRIS JEANETTE (CMT COMT)
Entity Type:Individual
Prefix:MRS
First Name:IRIS
Middle Name:JEANETTE
Last Name:DIAZ CASSIDY
Suffix:
Gender:F
Credentials:CMT COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 G STREET
Mailing Address - Street 2:#8 LA PLACITA
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201
Mailing Address - Country:US
Mailing Address - Phone:719-207-1402
Mailing Address - Fax:
Practice Address - Street 1:1548 G STREET
Practice Address - Street 2:#8 LA PLACITA
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201
Practice Address - Country:US
Practice Address - Phone:719-207-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3543225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist