Provider Demographics
NPI:1629543764
Name:DEWAN, COLLEEN (MEDAND EDS)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DEWAN
Suffix:
Gender:F
Credentials:MEDAND EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 CAINE DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-6124
Mailing Address - Country:US
Mailing Address - Phone:630-699-5543
Mailing Address - Fax:
Practice Address - Street 1:3727 CAINE DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-6124
Practice Address - Country:US
Practice Address - Phone:630-699-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool