Provider Demographics
NPI:1962870196
Name:LASSABE, REGINA M
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:LASSABE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E MAPLE ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-2200
Mailing Address - Country:US
Mailing Address - Phone:641-216-8217
Mailing Address - Fax:641-216-8218
Practice Address - Street 1:221 E STATE ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1813
Practice Address - Country:US
Practice Address - Phone:641-856-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2019-10-18
Deactivation Date:2019-09-24
Deactivation Code:
Reactivation Date:2019-10-14
Provider Licenses
StateLicense IDTaxonomies
IA104007626332BX2000X
IA086134101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962870196Medicaid
IA7510340001Medicare NSC