Provider Demographics
NPI:1689282253
Name:HARRIS, CASSANDRA (LMT)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E 3RD NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-4207
Mailing Address - Country:US
Mailing Address - Phone:307-389-0505
Mailing Address - Fax:
Practice Address - Street 1:617 BROADWAY ST STE C
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6380
Practice Address - Country:US
Practice Address - Phone:307-382-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11233815-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist