Healthcare Provider Details

I. General information

NPI: 1497949762
Provider Name (Legal Business Name): VAN BYSSUM ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 S MONTCLAIR AVE
GLEN ELLYN IL
60137-6357
US

IV. Provider business mailing address

174 S MONTCLAIR AVE
GLEN ELLYN IL
60137-6357
US

V. Phone/Fax

Practice location:
  • Phone: 630-858-0875
  • Fax: 630-858-0650
Mailing address:
  • Phone: 630-858-0875
  • Fax: 630-858-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.010527041.189584
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071004744
License Number StateIL

VIII. Authorized Official

Name: DR. DORIS M VAN BYSSUM
Title or Position: PRESIDENT/OWNER
Credential: PSY.D.
Phone: 630-858-0875