Healthcare Provider Details

I. General information

NPI: 1891827655
Provider Name (Legal Business Name): DWB HUMAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 N HERMITAGE AVE
CHICAGO IL
60613-1106
US

IV. Provider business mailing address

4350 N HERMITAGE AVE
CHICAGO IL
60613-1106
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-9356
  • Fax: 773-348-8220
Mailing address:
  • Phone: 773-327-9356
  • Fax: 773-348-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number071-006419
License Number StateIL

VIII. Authorized Official

Name: DR. DIANNA BOLEN
Title or Position: OWNER
Credential: PSYD
Phone: 773-327-9356