Provider Demographics
NPI:1790359388
Name:DILLEY, DUSTIN WAYNE (LICSW)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:WAYNE
Last Name:DILLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PROFESSIONAL PL STE 102&103
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0258
Mailing Address - Country:US
Mailing Address - Phone:304-848-5770
Mailing Address - Fax:
Practice Address - Street 1:65 PROFESSIONAL PL STE 102&103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0258
Practice Address - Country:US
Practice Address - Phone:304-848-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WVDP009459621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker