Healthcare Provider Details

I. General information

NPI: 1023015526
Provider Name (Legal Business Name): PATRICE LASSA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 W OHIO ST # 2
CHICAGO IL
60622-6036
US

IV. Provider business mailing address

1634 W OHIO ST # 2
CHICAGO IL
60622-6036
US

V. Phone/Fax

Practice location:
  • Phone: 773-450-8119
  • Fax: 800-507-4195
Mailing address:
  • Phone: 773-450-8119
  • Fax: 800-507-4195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-004014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: