Provider Demographics
NPI:1104969211
Name:DIANE GASSIRARO PC
Entity type:Organization
Organization Name:DIANE GASSIRARO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GASSIRARO
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:618-659-0959
Mailing Address - Street 1:1303 GERBER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:618-659-0959
Mailing Address - Fax:618-655-0995
Practice Address - Street 1:1303 GERBER WOODS DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-659-0959
Practice Address - Fax:618-655-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003239225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL496740634001Medicaid
IL$$$$$$$$$OtherSSN