Healthcare Provider Details

I. General information

NPI: 1164512182
Provider Name (Legal Business Name): DENNIS DELFOSSE LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 N BROADWAY ST SUITE 900, 910, 925
CHICAGO IL
60640-5266
US

IV. Provider business mailing address

4753 N BROADWAY ST SUITE 900, 910, 925
CHICAGO IL
60640-5266
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-2780
  • Fax: 773-989-2781
Mailing address:
  • Phone: 773-989-2780
  • Fax: 773-989-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number180-003164
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003164
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: