Provider Demographics
NPI:1205606894
Name:ROBERTSON, CASSIDY (PTA)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16810 INDIAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2421
Mailing Address - Country:US
Mailing Address - Phone:417-260-7046
Mailing Address - Fax:
Practice Address - Street 1:300 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-1647
Practice Address - Country:US
Practice Address - Phone:417-967-0900
Practice Address - Fax:417-967-0905
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021044011225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant