Provider Demographics
NPI:1073335675
Name:DUNMORE, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:DUNMORE
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 1:246 CLUBHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2059
Mailing Address - Country:US
Mailing Address - Phone:630-742-6899
Mailing Address - Fax:
Practice Address - Street 1:246 CLUBHOUSE ST
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-2059
Practice Address - Country:US
Practice Address - Phone:630-742-6899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490264061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical