Provider Demographics
NPI:1255853396
Name:DACANAY, ATHENA (PSYD)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:DACANAY
Suffix:
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:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0604
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6075
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-706-3190
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009576103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical