Provider Demographics
NPI:1295940864
Name:SMITH, KASSANDRA LYNN (COTA)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 TULIP TREE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4848
Mailing Address - Country:US
Mailing Address - Phone:260-484-8144
Mailing Address - Fax:
Practice Address - Street 1:729 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4215
Practice Address - Country:US
Practice Address - Phone:765-674-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant