Healthcare Provider Details

I. General information

NPI: 1609322791
Provider Name (Legal Business Name): DIANE BUBECK LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3528 BECKET LN
NAPERVILLE IL
60564-4141
US

IV. Provider business mailing address

3528 BECKET LN
NAPERVILLE IL
60564-4141
US

V. Phone/Fax

Practice location:
  • Phone: 630-664-9702
  • Fax: 630-369-5651
Mailing address:
  • Phone: 630-369-5645
  • Fax: 630-369-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.000604
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.001456
License Number StateIL

VIII. Authorized Official

Name: MRS. DIANE THERESE BUBECK
Title or Position: OWNER/PRESIDENT
Credential: RD, LMFT
Phone: 630-369-5645