Provider Demographics
NPI:1558540328
Name:BUBECK, DIANE (LMFT, RD, LDN, CLT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:BUBECK
Suffix:
Gender:F
Credentials:LMFT, RD, LDN, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 BECKET LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4141
Mailing Address - Country:US
Mailing Address - Phone:630-369-5645
Mailing Address - Fax:630-369-5651
Practice Address - Street 1:3528 BECKET LN
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4141
Practice Address - Country:US
Practice Address - Phone:630-369-5645
Practice Address - Fax:630-369-5651
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1640011456133V00000X
IL166.000604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered