Provider Demographics
NPI:1427405745
Name:ASD LIFE
Entity Type:Organization
Organization Name:ASD LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:630-631-9623
Mailing Address - Street 1:124 KRAML DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0303
Mailing Address - Country:US
Mailing Address - Phone:630-631-9623
Mailing Address - Fax:630-920-0522
Practice Address - Street 1:124 KRAML DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-631-9623
Practice Address - Fax:630-920-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-15-20882251C00000X
261QM0801X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty