Provider Demographics
NPI:1609209907
Name:FASSIH, ARDALAN (LMT)
Entity type:Individual
Prefix:
First Name:ARDALAN
Middle Name:
Last Name:FASSIH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CAMPBELL CIR UNIT 9
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3226
Mailing Address - Country:US
Mailing Address - Phone:610-608-0959
Mailing Address - Fax:
Practice Address - Street 1:100 CAMPBELL CIR UNIT 9
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-3226
Practice Address - Country:US
Practice Address - Phone:610-608-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-10
Last Update Date:2013-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG006218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist