Provider Demographics
NPI:1063515369
Name:VAN BYSSUM, DORIS M I (PSYD)
Entity type:Individual
Prefix:
First Name:DORIS
Middle Name:M
Last Name:VAN BYSSUM
Suffix:I
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 S MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6357
Mailing Address - Country:US
Mailing Address - Phone:630-858-0875
Mailing Address - Fax:630-858-0650
Practice Address - Street 1:1725 S NAPERVILLE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5805
Practice Address - Country:US
Practice Address - Phone:630-653-6441
Practice Address - Fax:630-653-8409
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004744103TC0700X
IL209.010527041.189584363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK44674Medicare PIN