Provider Demographics
NPI:1235224726
Name:DEWESE, TOMMIE D (LCSW,ACSW)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:D
Last Name:DEWESE
Suffix:
Gender:M
Credentials:LCSW,ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N. STONE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526
Mailing Address - Country:US
Mailing Address - Phone:708-352-2079
Mailing Address - Fax:
Practice Address - Street 1:1120 RANDALL COURT
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-232-1070
Practice Address - Fax:630-232-1471
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490010471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05373Medicare ID - Type Unspecified
ILQ12369Medicare UPIN