Provider Demographics
NPI:1770052250
Name:HA, KASSIDY LIEN (MOTR/L)
Entity type:Individual
Prefix:
First Name:KASSIDY
Middle Name:LIEN
Last Name:HA
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12760 S PARK AVE UNIT 363
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-3415
Mailing Address - Country:US
Mailing Address - Phone:801-443-7775
Mailing Address - Fax:801-447-0107
Practice Address - Street 1:12453 S 265 W STE B
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5420
Practice Address - Country:US
Practice Address - Phone:801-443-7775
Practice Address - Fax:801-447-0107
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10999463-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty