Healthcare Provider Details

I. General information

NPI: 1811087265
Provider Name (Legal Business Name): STEWART CASSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 10/30/2022
Certification Date: 10/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S MARY AVE STE 1
NIPOMO CA
93444-7821
US

IV. Provider business mailing address

1111 S BROADWAY STE 203
SANTA MARIA CA
93454-6682
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-3230
  • Fax: 805-929-3232
Mailing address:
  • Phone: 805-922-1711
  • Fax: 805-858-6828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6526
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: