Provider Demographics
NPI:1174112940
Name:GOLDTHWAIT, CASSIE LYN (LAC LMT)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:LYN
Last Name:GOLDTHWAIT
Suffix:
Gender:F
Credentials:LAC LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SENECA MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-2324
Mailing Address - Country:US
Mailing Address - Phone:607-857-8842
Mailing Address - Fax:
Practice Address - Street 1:2374 MOUND ROAD ROUTE 414
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165
Practice Address - Country:US
Practice Address - Phone:315-539-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026545225700000X
NY006854171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty