Provider Demographics
NPI:1609492669
Name:MAHAFFEY, DYLAN J (LPC)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:J
Last Name:MAHAFFEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 S MATTIS AVE APT T
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3692
Mailing Address - Country:US
Mailing Address - Phone:618-553-1086
Mailing Address - Fax:
Practice Address - Street 1:201 W SPRINGFIELD AVE STE 1005
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4968
Practice Address - Country:US
Practice Address - Phone:217-693-4918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015779101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty