Healthcare Provider Details

I. General information

NPI: 1619802485
Provider Name (Legal Business Name): DASIA MARTIN RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 S WESTERN AVE
CHICAGO IL
60609-2259
US

IV. Provider business mailing address

1450 N SEDGWICK ST APT 2137-2A
CHICAGO IL
60610-1249
US

V. Phone/Fax

Practice location:
  • Phone: 312-995-4412
  • Fax:
Mailing address:
  • Phone: 773-670-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: