Provider Demographics
NPI:1497764666
Name:BURGIN, DIANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:BURGIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:DIANNE
Other - Last Name:BURGIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2306 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2617
Mailing Address - Country:US
Mailing Address - Phone:847-328-2573
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:SUITE 606
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:312-222-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.002303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical