Provider Demographics
NPI:1659768885
Name:MALL, CASSANDRA (ATC, SCAT)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:MALL
Suffix:
Gender:F
Credentials:ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 BRIARCLIFF CT
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8122
Mailing Address - Country:US
Mailing Address - Phone:321-271-4028
Mailing Address - Fax:
Practice Address - Street 1:521 BRIARCLIFF CT
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8122
Practice Address - Country:US
Practice Address - Phone:321-271-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer