=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730198276
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY B. DOLIN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 12/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2530 CRAWFORD AVE SUITE 219
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-251-7350
-----------------------------------------------------
Fax | 847-853-2600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 E PEARSON ST #5301
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-649-9515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 886399211
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------