Provider Demographics
NPI:1700533742
Name:HAIRGROVE, CASSIDI
Entity type:Individual
Prefix:
First Name:CASSIDI
Middle Name:
Last Name:HAIRGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4427
Mailing Address - Country:US
Mailing Address - Phone:936-564-6907
Mailing Address - Fax:936-564-0509
Practice Address - Street 1:817 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4427
Practice Address - Country:US
Practice Address - Phone:936-564-6907
Practice Address - Fax:936-564-0509
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist