1689488744 NPI number — MARIO ANTLEY KASSA OTR/L,

Table of content: MARIO ANTLEY KASSA OTR/L, (NPI 1689488744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689488744 NPI number — MARIO ANTLEY KASSA OTR/L,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KASSA
Provider First Name:
MARIO
Provider Middle Name:
ANTLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689488744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 BREMERTON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-7263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-999-0175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 BREMERTON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-7263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-999-0175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  22860 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22860 . This is a "CALIFORNIA BOARD OF OCCUPATIONAL THERAPY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 2021005455 . This is a "MISSOURI DIVISION OF PROFESSIONAL REGISTRATION- OCCUPATIONAL THERAPY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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