=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245902543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEIDRE J. ROBINSON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2021
-----------------------------------------------------
Last Update Date | 10/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1830 SHERMAN AVE STE 404
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-3774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-508-3542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2741 EASTWOOD AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-1544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-508-3542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEIDRE J ROBINSON
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 312-508-3542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------