Provider Demographics
NPI:1700573714
Name:STANLEY, CASSIDY (PTA)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:STANLEY
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 1:1821 AZURE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2085
Mailing Address - Country:US
Mailing Address - Phone:702-985-1050
Mailing Address - Fax:
Practice Address - Street 1:7125 GRAND MONTECITO PKWY STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0261
Practice Address - Country:US
Practice Address - Phone:702-515-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1576225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant