Provider Demographics
NPI:1891933529
Name:MABBUTT, CASS (LAC, EAMP)
Entity Type:Individual
Prefix:
First Name:CASS
Middle Name:
Last Name:MABBUTT
Suffix:
Gender:F
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ALMON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2098
Mailing Address - Country:US
Mailing Address - Phone:208-882-8534
Mailing Address - Fax:208-882-6866
Practice Address - Street 1:324 W A ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2112
Practice Address - Country:US
Practice Address - Phone:360-920-2098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-245171100000X
WAWA60069719171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist