Healthcare Provider Details

I. General information

NPI: 1467360123
Provider Name (Legal Business Name): CASSIDY J GWYNN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 N 13TH ST
SHEBOYGAN WI
53081-3281
US

IV. Provider business mailing address

1125 N 13TH ST
SHEBOYGAN WI
53081-3281
US

V. Phone/Fax

Practice location:
  • Phone: 920-803-1617
  • Fax: 920-803-1622
Mailing address:
  • Phone: 920-803-1617
  • Fax: 920-803-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9265
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: