Healthcare Provider Details

I. General information

NPI: 1346912672
Provider Name (Legal Business Name): DYMOND HOLLINS CRC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

3321 W FLOURNOY ST
CHICAGO IL
60624-3717
US

V. Phone/Fax

Practice location:
  • Phone: 773-937-2745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013915
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number00380989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: