Healthcare Provider Details

I. General information

NPI: 1285341941
Provider Name (Legal Business Name): CASSIDY LEIGH ICENHOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N ERIE HWY STE A
HAMILTON OH
45011-4264
US

IV. Provider business mailing address

248 TRIPLE CROWN DR
LEBANON OH
45036-8023
US

V. Phone/Fax

Practice location:
  • Phone: 513-887-3710
  • Fax:
Mailing address:
  • Phone: 501-744-9594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT012243
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: