Provider Demographics
NPI:1790892057
Name:DEAN, MARILYN R (PSYD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:R
Last Name:DEAN
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:C3800 HEARTLAND HILLS RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54484-9488
Mailing Address - Country:US
Mailing Address - Phone:715-223-7282
Mailing Address - Fax:
Practice Address - Street 1:C3800 HEARTLAND HILLS RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:WI
Practice Address - Zip Code:54484-9488
Practice Address - Country:US
Practice Address - Phone:715-223-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1161103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39696100Medicaid
WI39696100Medicaid
WI004A72200Medicare ID - Type Unspecified