Provider Demographics
NPI:1740604644
Name:WIDENER, CASSANDRA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WIDENER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3606
Mailing Address - Country:US
Mailing Address - Phone:307-672-2092
Mailing Address - Fax:307-673-1969
Practice Address - Street 1:13336 INDUSTRIAL RD STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137
Practice Address - Country:US
Practice Address - Phone:402-330-3211
Practice Address - Fax:402-330-5970
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2204225X00000X
WYOTR-1138225X00000X
IDOT-1117225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$00Medicaid