Provider Demographics
NPI:1073964086
Name:DASSA, SABREEN
Entity Type:Individual
Prefix:
First Name:SABREEN
Middle Name:
Last Name:DASSA
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 1:15232 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1507
Mailing Address - Country:US
Mailing Address - Phone:708-983-4580
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1367
Practice Address - Country:US
Practice Address - Phone:309-298-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073964086Medicaid