Provider Demographics
NPI:1134441108
Name:DIVELBISS, RICHARD (LSW,MBA,CADC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DIVELBISS
Suffix:
Gender:M
Credentials:LSW,MBA,CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5038
Mailing Address - Country:US
Mailing Address - Phone:630-668-8710
Mailing Address - Fax:630-668-8779
Practice Address - Street 1:618 S WEST ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5038
Practice Address - Country:US
Practice Address - Phone:630-668-8710
Practice Address - Fax:630-668-8779
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.008305104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.008305OtherSTATE LICENSE NUMBER