1194885772 NPI number — MS. CASSANDRA ELAINE WRIGHT OTR

Table of content: MS. CASSANDRA ELAINE WRIGHT OTR (NPI 1194885772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194885772 NPI number — MS. CASSANDRA ELAINE WRIGHT OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
CASSANDRA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAIRLEY
Provider Other First Name:
CASSANDRA
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194885772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30132-0041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-861-5581
Provider Business Mailing Address Fax Number:
770-505-0709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2137 SUMMERCHASE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-8140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-861-5581
Provider Business Practice Location Address Fax Number:
770-505-0709
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT003282 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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