Provider Demographics
NPI:1962879825
Name:DIESCHBOURG, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DIESCHBOURG
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 1:11243 E CHESAPEAKE PL
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5928
Mailing Address - Country:US
Mailing Address - Phone:708-369-3935
Mailing Address - Fax:
Practice Address - Street 1:333 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5646
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD21672589325101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXOF890603919OtherBLUE CROSS BLUESHIELD