Healthcare Provider Details

I. General information

NPI: 1124401534
Provider Name (Legal Business Name): KASSIDY DIAZ DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KASSIDY MCLEAN

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 E MAIN ST
MIDDLETOWN DE
19709-1462
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 919-258-2714
  • Fax: 410-648-4878
Mailing address:
  • Phone: 919-258-2714
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberPT026076
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0003367
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: