Provider Demographics
NPI:1912786443
Name:HASSOUN, SURA MOHAMED (OTR/L)
Entity Type:Individual
Prefix:
First Name:SURA
Middle Name:MOHAMED
Last Name:HASSOUN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MEMORIAL DR APT 301B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4647
Mailing Address - Country:US
Mailing Address - Phone:617-682-5468
Mailing Address - Fax:
Practice Address - Street 1:179 BEAR HILL RD STE 105
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1063
Practice Address - Country:US
Practice Address - Phone:781-895-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist