Provider Demographics
NPI:1003641499
Name:DIMMICK, SPENCER
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:DIMMICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 W CORNELIA AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2743
Mailing Address - Country:US
Mailing Address - Phone:508-561-3214
Mailing Address - Fax:
Practice Address - Street 1:2732 N CLARK ST STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1553
Practice Address - Country:US
Practice Address - Phone:773-250-1769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health