Provider Demographics
NPI:1518459981
Name:DORIWALA, TASNEEM
Entity Type:Individual
Prefix:
First Name:TASNEEM
Middle Name:
Last Name:DORIWALA
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 1:1654 ASHBURY LN
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4887
Mailing Address - Country:US
Mailing Address - Phone:815-260-0705
Mailing Address - Fax:
Practice Address - Street 1:1654 ASHBURY LN
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4887
Practice Address - Country:US
Practice Address - Phone:815-260-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-36512106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician