Provider Demographics
NPI:1639867237
Name:CASIDY, CAMERYN ALYSSA (MT)
Entity Type:Individual
Prefix:
First Name:CAMERYN
Middle Name:ALYSSA
Last Name:CASIDY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 HILDEBRAND LN NE STE 102
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2824
Mailing Address - Country:US
Mailing Address - Phone:425-287-9368
Mailing Address - Fax:
Practice Address - Street 1:911 HILDEBRAND LN NE STE 102
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2824
Practice Address - Country:US
Practice Address - Phone:206-842-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61282823225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist