Healthcare Provider Details

I. General information

NPI: 1811732043
Provider Name (Legal Business Name): RUBY KOLTUN DIENSTAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 W LAWRENCE AVE
CHICAGO IL
60640-4702
US

IV. Provider business mailing address

7076 N WOLCOTT AVE APT 3
CHICAGO IL
60626-2382
US

V. Phone/Fax

Practice location:
  • Phone: 773-569-1468
  • Fax:
Mailing address:
  • Phone: 718-644-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: