Provider Demographics
NPI:1710459789
Name:WHITE, DYAMON (RBT-18-74573)
Entity Type:Individual
Prefix:
First Name:DYAMON
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:RBT-18-74573
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1566
Mailing Address - Country:US
Mailing Address - Phone:847-306-9843
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1566
Practice Address - Country:US
Practice Address - Phone:847-306-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-74573106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician