Provider Demographics
NPI:1417089293
Name:BOLEN, DIANNA W (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:W
Last Name:BOLEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1106
Mailing Address - Country:US
Mailing Address - Phone:773-327-9356
Mailing Address - Fax:773-348-8220
Practice Address - Street 1:4350 N HERMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1106
Practice Address - Country:US
Practice Address - Phone:773-327-9356
Practice Address - Fax:773-348-8220
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006419103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632869OtherBCBS
IL205656Medicare ID - Type Unspecified