Healthcare Provider Details

I. General information

NPI: 1497368922
Provider Name (Legal Business Name): DEBORAH N DYSLIN KMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 1310
CHICAGO IL
60611-2923
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 1310
CHICAGO IL
60611-2923
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-9627
  • Fax: 312-695-6072
Mailing address:
  • Phone: 312-695-9627
  • Fax: 312-695-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149022450
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022450
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: