Provider Demographics
NPI:1972661189
Name:FONDA, DICKELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DICKELLE
Middle Name:
Last Name:FONDA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 DARROW AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1114
Mailing Address - Country:US
Mailing Address - Phone:847-491-9748
Mailing Address - Fax:
Practice Address - Street 1:1220 DARROW AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1114
Practice Address - Country:US
Practice Address - Phone:847-491-9748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical