Provider Demographics
NPI:1053699546
Name:HAKE, CASSANDRA RAE
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:RAE
Last Name:HAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61607-2517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6303 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:IL
Practice Address - Zip Code:61607-2517
Practice Address - Country:US
Practice Address - Phone:309-363-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370686250001Medicaid