MEDICARE: DR. AUGUSTINE LANSANA MA, DMIN, PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	BHOO4017	PA

General Provider Information

NPI Number	:	1033890116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUGUSTINE LANSANA MA, DMIN, PH.D.

Provider Business Mailing Address
First Line	:	6236 N HOYNE AVE APT AB
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3023
Country	:	US
Telephone Number	:	412-853-2586
Fax Number	:

Provider Business Practice Location Address
First Line	:	5447 W ADDISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-3203
Country	:	US
Telephone Number	:	412-853-2586
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	07/31/2023

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