Provider Demographics
NPI:1326114562
Name:DILLON, CHARLOTTE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ANN
Last Name:DILLON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N LAKE ST
Mailing Address - Street 2:SUITE 204 GATEWAY PROFESSIONAL SERVICES
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4106
Mailing Address - Country:US
Mailing Address - Phone:630-896-2337
Mailing Address - Fax:630-896-3515
Practice Address - Street 1:412 N LAKE ST
Practice Address - Street 2:SUITE 204 GATEWAY PROFESSIONAL SERVICES
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4106
Practice Address - Country:US
Practice Address - Phone:630-896-2337
Practice Address - Fax:630-896-3515
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004310103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4572030OtherBC BS OF ILLINOIS
IL4515275OtherBC BS OF ILLINOIS
IL4572030OtherBC BS OF ILLINOIS