Healthcare Provider Details

I. General information

NPI: 1063515369
Provider Name (Legal Business Name): DORIS M VAN BYSSUM I PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 S NAPERVILLE RD SUITE 206
WHEATON IL
60189-5805
US

IV. Provider business mailing address

174 S MONTCLAIR AVE
GLEN ELLYN IL
60137-6357
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-6441
  • Fax: 630-653-8409
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 Number071-004744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: