Provider Demographics
NPI:1215764337
Name:BACON, DAWN
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3911
Mailing Address - Country:US
Mailing Address - Phone:773-673-7449
Mailing Address - Fax:
Practice Address - Street 1:3541 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3911
Practice Address - Country:US
Practice Address - Phone:773-673-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician