Provider Demographics
NPI:1689018624
Name:DIZEN, MUGE
Entity Type:Individual
Prefix:
First Name:MUGE
Middle Name:
Last Name:DIZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8630
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1813 W KIRBY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5410
Practice Address - Country:US
Practice Address - Phone:217-383-1850
Practice Address - Fax:217-383-3439
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist