=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144665118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WENDY B. DOLIN, LCSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2013
-----------------------------------------------------
Last Update Date | 12/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2530 CRAWFORD AVE SUITE 219
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-910-2346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2530 CRAWFORD AVE SUITE 219
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | WENDY B. DOLIN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-910-2346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.012817
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------