Basic Information
| Provider Information | |||||||||
| NPI: | 1962879825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIESCHBOURG | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11243 E CHESAPEAKE PL | ||||||||
| Address2: | |||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083693935 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 N LA GRANGE RD | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605265646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087455277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | D21672589325 | IL | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | XOF890603919 | 01 | IL | BLUE CROSS BLUESHIELD | OTHER |