Provider Demographics
NPI:1528393188
Name:FAIRFIELD, KACEY SHIZUKA (MPT)
Entity type:Individual
Prefix:MRS
First Name:KACEY
Middle Name:SHIZUKA
Last Name:FAIRFIELD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:KACEY
Other - Middle Name:SHIZUKA
Other - Last Name:OKUDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1450 AVIATION DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8767
Mailing Address - Country:US
Mailing Address - Phone:208-720-8311
Mailing Address - Fax:
Practice Address - Street 1:1450 AVIATION DR STE 201
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8767
Practice Address - Country:US
Practice Address - Phone:208-720-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist