Provider Demographics
NPI:1578093159
Name:CHANDLER, KASSIDY SHAYE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KASSIDY
Middle Name:SHAYE
Last Name:CHANDLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:KASSIDY
Other - Middle Name:SHAYE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1347 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1309
Mailing Address - Country:US
Mailing Address - Phone:334-618-1764
Mailing Address - Fax:334-746-7688
Practice Address - Street 1:1347 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1309
Practice Address - Country:US
Practice Address - Phone:334-618-1764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16338235Z00000X
AL4257235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103540800Medicaid