1932563426 NPI number — SOLID GROUND BEHAVIORAL SERVICES

Table of content: ANTONIO DI STASI M.D. (NPI 1801211958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932563426 NPI number — SOLID GROUND BEHAVIORAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLID GROUND BEHAVIORAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1932563426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11940 S SPRINGFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALSIP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60803-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-969-4109
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11940 S SPRINGFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALSIP
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60803-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-969-4109
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MASON-BORDEN
Authorized Official First Name:
INONGE LATANYA
Authorized Official Middle Name:
Authorized Official Title or Position:
BCBA
Authorized Official Telephone Number:
708-969-4109

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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