Provider Demographics
NPI:1689320517
Name:SMITH, SYDNEY CASCADE (LMT)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:CASCADE
Last Name:SMITH
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 1:3270 N MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4173
Mailing Address - Country:US
Mailing Address - Phone:907-388-7644
Mailing Address - Fax:
Practice Address - Street 1:16150 N HIGH DESERT ST STE 112
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5567
Practice Address - Country:US
Practice Address - Phone:208-442-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3344225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-3344OtherMASSAGE THERAPY LICENSE