Healthcare Provider Details

I. General information

NPI: 1780229054
Provider Name (Legal Business Name): AISSATOU DIALLO RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELWYN RD
MEDIA PA
19063-4622
US

IV. Provider business mailing address

583 SHOEMAKER RD STE 230
KING OF PRUSSIA PA
19406-4238
US

V. Phone/Fax

Practice location:
  • Phone: 610-891-7007
  • Fax:
Mailing address:
  • Phone: 484-681-2170
  • Fax: 484-320-8307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-104100
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: