Provider Demographics
NPI:1609481167
Name:QUALLS, CASSIDY SHANNON (OTD)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:SHANNON
Last Name:QUALLS
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:MONETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72447-0277
Mailing Address - Country:US
Mailing Address - Phone:870-919-4252
Mailing Address - Fax:
Practice Address - Street 1:1107 E MATTHEWS AVE STE 105
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4315
Practice Address - Country:US
Practice Address - Phone:870-333-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist