Provider Demographics
NPI:1497949762
Name:VAN BYSSUM ASSOCIATES, PC
Entity Type:Organization
Organization Name:VAN BYSSUM ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN BYSSUM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-858-0875
Mailing Address - Street 1:174 S MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6357
Mailing Address - Country:US
Mailing Address - Phone:630-858-0875
Mailing Address - Fax:630-858-0650
Practice Address - Street 1:174 S MONTCLAIR AVE
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6357
Practice Address - Country:US
Practice Address - Phone:630-858-0875
Practice Address - Fax:630-858-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004744103TC0700X
IL209.010527041.189584363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL704040Medicare PIN