Provider Demographics
NPI:1942973201
Name:WEATHERSPOON, DARLA
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:
Last Name:WEATHERSPOON
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 1:124 W 111TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4204
Mailing Address - Country:US
Mailing Address - Phone:773-386-5936
Mailing Address - Fax:
Practice Address - Street 1:939 GALENA SQUARE DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1355
Practice Address - Country:US
Practice Address - Phone:773-386-5936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)